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Social Network Analysis: Building Partnerships for Healthy Communities

Maryland Department of Health and Mental Hygiene

Center for Chronic Disease Prevention and Control

September 30, 2015

Social Network Analysis: Building Partnerships for Healthy Communities

Final Report

Submitted to: Kristi Pier, MHS, MCHES

Director, Center for Chronic Disease Prevention and Control Maryland Department of Health and Mental Hygiene

Submitted by: Aaron Wachhaus, PhD, Faculty Fellow and Assistant Professor

Kenneth Weaver, Graduate Fellow

Schaefer Center for Public Policy University of Baltimore – College of Public Affairs

1420 N. Charles Street Baltimore, MD 21201

410.837.6188 [email protected] September 30, 2015

mailto:[email protected]

ACKNOWLEDGEMENTS

The following Schaefer Center staff members played key roles in the collection and analysis of the data included in this document.

P. Ann Cotten, DPA, CPA, Director

Mary Lovegrove, JD, MBA, Assistant Director

William Wells, MPA, Survey Research Manager

Jim Bradley, MS, BSEE, Senior Computer Programmer The research team is appreciative of the work of staff of the Maryland Department of Health and Mental Hygiene. The team would like to specifically acknowledge:

Jenelle Mayer, Director of Community Health, Allegany

Laura Fox, Director, Chronic Disease Prevention, Baltimore

Emilie Gilde, Program Director, Tobacco Use and Cardiovascular Disease Prevention, Baltimore

Erin Penniston, Childhood and Wellness Coordinator

Cathleen Bilodeau, Program Director, Wellness Promotions, Caroline County

Heather Reed, Health Educator, Caroline County

Miranda LeCompte, Program Coordinator, Dorchester County

Sandy Wilson, Health Education Program Manager, Dorchester County

Kendra McLaughlin, Director, Health Education, Garrett County

Amy Ritchie, Nutritionist & 1422 Coordinator, Garrett County

Matey Barker, Director, Behavioral Health, Somerset County

Crystal Bell, Coordinator of Special Programs, Somerset County

Mary McPherson, Program Manager, Washington County

Cara Rozaieski, Health Education Supervisor, Wicomico County

Marty Pusey, Director of Prevention Services, Worcester County

Mimi Dean, Chronic Disease Prevention and Tobacco Program Supervisor, Worcester County

This publication was supported by the Cooperative Agreement 1U58DP005487-01 from the Centers for Disease Control and Prevention through the Maryland Department of Health and Mental Hygiene’s Center for Chronic

Disease Prevention and Control.

ABOUT THE SCHAEFER CENTER FOR PUBLIC POLICY

Established in 1985 with a mission to bring the University of Baltimore’s academic expertise to bear in solving problems faced by government and nonprofit organizations, the Schaefer Center has grown into one of Maryland’s preeminent policy centers offering invaluable assistance in support of Maryland’s public sector. Housed in the University of Baltimore’s College of Public Affairs, the Schaefer Center is able to complement the College’s professional staff by drawing upon the expertise of faculty and students in its three schools—Criminal Justice, Health and Human Services, Public and International Affairs—in their research, consulting, and professional development work. The Schaefer Center offers program evaluation, policy analysis, survey research, strategic planning, workload studies, opinion research, management consulting, and professional development services. It is through the Schaefer Center that the University of Baltimore and the College of Public Affairs meet a central component of the University’s mission of applied research and public service to the Baltimore metropolitan area and the state of Maryland. Since its creation 30 years ago, the Schaefer Center has completed hundreds of research and professional development projects for various local, state, and federal agencies, as well as nonprofit organizations. Through our newest program, the Maryland Certified Public Manager® Program, the Schaefer Center is building management capacity in Maryland’s public organizations. This program is offered to nonprofit and government managers. For information about contracting with the Schaefer Center, please contact its director, Ann Cotten, at 410-837-6185 or [email protected].

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TABLE OF CONTENTS

Executive Summary ....................................................................................................................... 1

Social Network Analysis: Key Measures .................................................................................... 1

Findings ...................................................................................................................................... 2

Baltimore City ........................................................................................................................ 2

Washington County ............................................................................................................... 2

Western Maryland ................................................................................................................. 3

Lower Shore ........................................................................................................................... 3

Caroline & Dorchester Counties ............................................................................................ 3

Social Network Analysis: Survey Overview ................................................................................... 5

Identifying Key Healthcare Organizations ................................................................................. 5

Survey Data Collection .............................................................................................................. 6

Snowball Sampling Results .................................................................................................... 6

Online Survey ........................................................................................................................ 7

Online Survey Response Rates .............................................................................................. 8

Introduction to Social Network Analysis ..................................................................................... 10

Social Network Analysis: An Example...................................................................................... 10

Social Network Analysis in Social Settings .......................................................................... 11

Creating a Network Visualization ............................................................................................ 11

Visualizing the Network with Incoming Connections ......................................................... 12

Visualizing the Network with Outgoing Connections ......................................................... 14

Betweenness (groups that act as bridges to others) .......................................................... 15

Social Network Analysis: Key Concepts ................................................................................... 16

Network Composition ......................................................................................................... 16

Density ................................................................................................................................. 16

Degree Centrality................................................................................................................. 17

Direction of Connections ..................................................................................................... 17

Betweenness Centrality ....................................................................................................... 17

Baltimore City: Social Network Analysis Results ......................................................................... 19

Response Rate ......................................................................................................................... 19

Healthcare Organization Sectors ............................................................................................. 19

Network Data .......................................................................................................................... 20

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Density ................................................................................................................................. 20


Out-Degree Centrality ......................................................................................................... 24

Betweenness Centrality (bridge organizations) .................................................................. 27

Network Geographics .............................................................................................................. 29

Mapping Out The Locations of Healthcare Organizations in Baltimore City ...................... 29

Baltimore City: Discussion & Recommendations .................................................................... 31

Reciprocal Relationships ..................................................................................................... 31

Clustered Organizations Within Baltimore City .................................................................. 33

Leverage Opportunities Arising From This Study .................................................................... 38

Network Evaluation ............................................................................................................. 38

Partner Aawareness ............................................................................................................ 38

Encourage the Growth of Lateral Connections on the Periphery ....................................... 39

Baltimore City: Survey Results and Key Information .................................................................. 40

Survey Respondents and Organizations .............................................................................. 40

Survey Completion Rates for Major Organizations ............................................................. 40

Survey Questions and Answers ................................................................................................... 41

Section 1: Baltimore City Health Organizations ...................................................................... 41

Questions 1 and 2: Healthcare Organizations: Names/Division/Department .................... 41

Question 3: Survey Respondents’ Job Titles ....................................................................... 41

Question 4: Healthcare Organizations: Business Sector ..................................................... 42

Question 5: Diabetes Program Partners (DPP).................................................................... 42

Question 6: Healthcare Organizations: Focus ..................................................................... 44

Section 2: Baltimore City Health Organizations: Relationships .............................................. 44

Question 7: Healthcare Organizations’ Frequent Partners ................................................. 44

Religious Organizations in Baltimore .................................................................................. 46

Section 3: Baltimore City Health Organizations: Relationship Quality ................................... 46

Question 8: Upstream and Downstream Relationships ...................................................... 46

Question 9: Length of Relationships Between Organizations ............................................. 47

Question 10: Frequency of Communication Between Organizations ................................. 48

Question 11: Organizations’ Understanding of Partner Skill and Knowledge .................... 50

Question 12: Healthcare Organizations: Communication .................................................. 51

In-Person Meetings ............................................................................................................. 51

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Washington County: Social Network Analysis Results ................................................................ 53

Response Rate ......................................................................................................................... 53


Density ................................................................................................................................. 53

In-Degree Centrality ............................................................................................................ 54

In-Degree Centrality: A Visualization .................................................................................. 54

Organizations with Outgoing Connections.......................................................................... 56


Betweenness Centrality (bridge organizations visualization) ............................................. 58


Washington County: Discussion & Recommendations ........................................................... 62


Leveraging Opportunities Arising From This Study ................................................................. 64


Partner Organizations ......................................................................................................... 64

Encourage the Growth of Lateral Connections on the Periphery ....................................... 65

Washington County: Survey Results and Key Information ......................................................... 66

Washington County Survey Respondents ........................................................................... 66



Section 1: Washington County Health Organizations ............................................................. 67






Section 2: Washington County Health Organizations: Relationships ..................................... 69


Section 3: Washington County Health Organizations: Relationship Quality .......................... 70




Question 11: Organizations’ Understanding of Partner Skill and Knowledge .................... 73

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Question 12: Healthcare Organizations: Communication .................................................. 74

In-Person Meetings ............................................................................................................. 75

Allegany/Garrett Counties: Social Network Analysis Results ...................................................... 77

Response Rate ......................................................................................................................... 77


Density ................................................................................................................................. 77


In-Degree Centrality: A Visualization .................................................................................. 79

Out-Degree Centrality ......................................................................................................... 80


Betweenness Centrality: A Visualization ............................................................................. 81


Discussion & Recommendations ............................................................................................. 85

Western MD Network (Health Systems Only) ..................................................................... 86

Western MD Network – Without Health Systems Organizations ....................................... 87


Leverage Opportunities Arising From This Study .................................................................... 90


Partner Organizations ......................................................................................................... 90

Encourage the Growth of Lateral Connections on the Periphery ........................................... 91

Allegany/Garrett County: Survey Results and Key Information .................................................. 92

Allegany/Garrett County Survey Respondents ................................................................... 92



Section 1: Allegany/Garrett County Health Organizations ..................................................... 93






Section 2: Healthcare Organizations: Relationships ............................................................... 95


Section 3: Healthcare Organizations: Relationship Quality .................................................... 97

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Question 11: Organizations’ Understanding of Partner Skill and Knowledge .................. 100

Question 12: Healthcare Organizations: Communication ................................................ 101

In-Person Meetings ........................................................................................................... 102

Somerset, Wicomico, and Worcester Counties: Social Network Analysis Results ................... 104

Response Rate ................................................................................................................... 104

Network Demographics ..................................................................................................... 104

Density ............................................................................................................................... 104

Degree Centrality............................................................................................................... 105

In-Degree Centrality .......................................................................................................... 105

Out-Degree Centrality ....................................................................................................... 107

Betweenness Centrality (Bridge organizations) ................................................................ 107

Betweenness Centrality: A Visualization ........................................................................... 109

Network Geographics ............................................................................................................ 110

Lower Shore: Discussion & Recommendations ..................................................................... 112

Reciprocal Relationships ................................................................................................... 113

Leveraging Opportunities Arising From This Study ............................................................... 114

Network Evaluation ........................................................................................................... 114

Partner Organizations ....................................................................................................... 114

Encourage the Growth of Lateral Connections on the Periphery ..................................... 115

Somerset, Wicomico, and Worcester Counties: Survey Results and Key Information ............. 116

Survey Respondents .......................................................................................................... 116

Survey Completion Rates for Major Organizations ........................................................... 116

Survey Questions and Answers ................................................................................................. 117

Section 1: Somerset/Wicomico/Worcester Counties Health Organizations ........................ 117

Questions 1 and 2: Healthcare Organizations: Names/Division/Department .................. 117

Question 3: Survey Respondents’ Job Titles ..................................................................... 117

Question 4: Healthcare Organizations: Business Sector ................................................... 118

Question 5: Diabetes Program Partners (DPP).................................................................. 118

Question 6: Healthcare Organizations: Focus ................................................................... 119

Section 2: Healthcare Organizations: Relationships ............................................................. 119

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Question 7: Healthcare Organizations’ Frequent Partners ............................................... 119

Importance of Non-Traditional Organizations .................................................................. 120

Section 3: Healthcare Organizations: Relationship Quality .................................................. 121

Question 8: Upstream and Downstream Relationships .................................................... 121

Question 9: Length of Relationships Between Organizations ........................................... 122

Question 10: Frequency of Communication Between Organizations ............................... 123




Caroline and Dorchester Counties: Social Network Analysis Results ....................................... 127

Response Rate ................................................................................................................... 127

Healthcare Organizations by Sector .................................................................................. 127

Density ............................................................................................................................... 127

Degree Centrality............................................................................................................... 128

In-Degree Centrality: A Visualization ................................................................................ 129

Out-Degree Centrality ....................................................................................................... 130

Betweenness Centrality (bridge organizations) ................................................................ 130

Betweenness Centrality: A Visualization ........................................................................... 132

Network Geographics ............................................................................................................ 133

Discussion & Recommendations ........................................................................................... 135

Reciprocal Relationships ................................................................................................... 137

Betweenness Centrality (bridge organizations) ................................................................ 137

Leveraging Opportunities Arising From This Study ............................................................... 138

Network Evaluation ........................................................................................................... 138

Partner Organizations ....................................................................................................... 138

Encourage the Growth of Lateral Connections on the Periphery ..................................... 139

Caroline and Dorchester Counties: Survey Results and Key Information ................................. 140

Survey Respondents .......................................................................................................... 140

Survey Completion Rates for Major Organizations ........................................................... 140

Survey Questions and Answers ................................................................................................. 141

Section 1: Healthcare Organizations: Information ................................................................ 141

Questions 1 and 2: Healthcare Organizations: Names/Division/Department .................. 141

Question 3: Survey Respondents’ Job Titles ..................................................................... 141

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Question 4: Healthcare Organizations: Business Sector ................................................... 142

Question 5: Diabetes Program Partners (DPP).................................................................. 142

Question 6: Healthcare Organizations: Focus ................................................................... 143

Section 2: Healthcare Organizations: Relationships ............................................................. 143

Question 7: Healthcare Organizations’ Frequent Partners ............................................... 143

Section 3: Healthcare Organizations: Relationship Quality .................................................. 144

Question 8: Upstream and Downstream Relationships .................................................... 145

Question 9: Length of Relationships Between Organizations ........................................... 146

Question 10: Frequency of Communication Between Organizations ............................... 146




References ................................................................................................................................. 151

Appendix A: Query Letter for Snowball Sample ........................................................................ 152

Appendix B: Online Survey ........................................................................................................ 154

Appendix C: Baltimore City Organizations – Degree and Centrality Scores ............................. 157

Appendix D: Washington County Organizations – Degree and Centrality Scores .................... 165

Appendix E: Western Maryland Organizations – Degree and Centrality Scores ...................... 168

Appendix F: Lower Shore Organizations – Degree and Centrality Scores ................................ 170

Appendix G: Caroline and Dorchester County Organizations – Degree and Centrality Scores 172

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LIST OF TABLES

Table 1: Data Collection Methods ................................................................................................. 6

Table 2: Online Survey Response Data .......................................................................................... 9

Table 3: Sample Network Matrix ................................................................................................. 10

Table 1-1: Organization Totals by Sector .................................................................................... 19

Table 1-2: Organization Totals by Sector In-degree Centrality, Baltimore City .......................... 22

Table 1-3: Organizations with Out-Degree, but No In-Degree Centrality ................................... 23

Table 1-4: Out-Degree Centrality, Baltimore City ....................................................................... 24

Table 1-5: Betweenness Centrality, Baltimore City ..................................................................... 27

Table 1-6: The Top 25 Healthcare Organizations in Baltimore City (by % selected in the survey)

..................................................................................................................................................... 45

Table 1-7: Organizations with the Highest Number of Downstream Partners .......................... 47

Table 1-8: Organizations with the Highest Number of Partner Relationships Longer Than 10 Years

..................................................................................................................................................... 48

Table 1-9: Organizations with the Highest Level of Frequent Contact with their Partners ....... 49

Table 1-10: Top 25 Organizations where In-Person Meetings are the Primary Means of

Communication with Survey Respondents ................................................................................. 52

Table 2-1: Network Organization Count by Sector ..................................................................... 53

Table 2-2: In-degree Centrality, Washington County.................................................................. 54

Table 2-3: Out-degree Centrality, Washington County ............................................................... 56

Table 2-4: Organizations with Outgoing Connections, but No Reported Incoming Connections

..................................................................................................................................................... 57

Table 2-5: Betweenness Centrality, Washington County............................................................ 58

Table 2-6: Private Business Organizations in the Washington County Network ........................ 62

Table 2-7: Top 20 Healthcare Organizations in Washington County (by % selected in the survey)

..................................................................................................................................................... 70

Table 2-8: Top 20 Organizations with the Highest Number of Downstream Partners .............. 71


..................................................................................................................................................... 72

Table 2-10: Organizations with the Highest Level of Frequent Contact with their Partners ..... 73

Table 2-11: Organizations where In-Person Meetings are the Primary Means of Communication

with Survey Respondents ............................................................................................................ 76

Table 3-1: Network Organization Count by Sector ..................................................................... 77

Table 3-2: In-degree Centrality, Western Maryland ................................................................... 78

Table 3-3: Out-degree Centrality, Western Maryland ................................................................ 80

Table 3-4: Betweenness Centrality, Western MD ....................................................................... 81

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Table 3-5: Most-Connected Healthcare Organizations in Allegany/Garrett County (by % selected

in the survey) ............................................................................................................................... 96

Table 3-6: Organizations with the Highest Number of Downstream Partners .......................... 98


..................................................................................................................................................... 99

Table 3-8: Top 20 Organizations with Highest Level of Frequent Contact with their Partners 100


with Survey Respondents .......................................................................................................... 103

Table 4-1: Network Organization Count by Sector ................................................................... 104

Table 4-2: In-degree Centrality, Lower Shore ........................................................................... 105

Table 4-3: Out-degree centrality, Lower Shore ......................................................................... 107

Table 4-4: Betweenness Centrality, Lower Shore ..................................................................... 108

Table 4-5: Most-Connected Healthcare Organizations, Lower Shore (by % selected in the survey)

................................................................................................................................................... 120

Table 4-6: Organizations with the Highest Number of Downstream Partners ........................ 121


................................................................................................................................................... 122


Table 4-9: Top 20 Organizations where In-Person Meetings are the Primary Means of

Communication with Survey Respondents ............................................................................... 126

Table 5-1: Network Organization Count by Sector ................................................................... 127

Table 5-2: In-degree Centrality, Caroline & Dorchester Counties ............................................ 128

Table 5-3: Out-degree centrality, Caroline & Dorchester Counties .......................................... 130

Table 5-4: Betweenness Centrality, Caroline & Dorchester Counties ...................................... 131

Table 5-5: Betweenness Centrality Scores for Caroline & Dorchester Counties ...................... 137

Table 5-6: Top 20 Healthcare Organizations in Caroline/Dorchester Counties (by % selected in

the survey) ................................................................................................................................. 144

Table 5-7: Organizations with the Highest Number of Downstream Partners, Caroline and

Dorchester Counties .................................................................................................................. 145


................................................................................................................................................... 146



with Survey Respondents .......................................................................................................... 150

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LIST OF FIGURES

Figure 1: Online Survey Response Rates by Network ................................................................... 8

Figure 2: Visualization of Sample Network ................................................................................. 12

Figure 3: Sample Network, in-degree centrality ......................................................................... 13

Figure 4: Sample Network, out-degree centrality ....................................................................... 14

Figure 5: Sample Network, betweenness centrality ................................................................... 15

Figure 1-1: Baltimore City – Network Visualization .................................................................... 21

Figure 1-2: Baltimore City, Node Size by In-Degree Centrality ................................................... 25

Figure 1-3: Baltimore City, In-Degree Count of 7 or Higher ........................................................ 26

Figure 1-4: Baltimore City, Betweenness by Sector .................................................................... 28

Figure 1-5: Distribution of Healthcare Organizations in Baltimore City ..................................... 30

Figure 1-6: Baltimore City, Reciprocal Connections .................................................................... 32

Figure 1-7: Baltimore City, Large Organizations Grouped Together ........................................... 34

Figure 1-8: Baltimore City, Large Organizations Removed ......................................................... 35

Figure 1-9: Baltimore City: No Cluster Organizations, American Heart Association or American

Diabetes Association ................................................................................................................... 36

Figure 1-10: Partial Baltimore City Network by Betweenness Centrality ................................... 37

Figure 1-11: Online Survey (Q3) – Survey Respondent Job Titles in Baltimore City .................. 42

Figure 1-12: Online Survey (Q5) – Diabetes Program Partners .................................................. 43

Figure 1-13: Online Survey (Q6) – Organization Focus: Healthcare Awareness/Service Delivery

..................................................................................................................................................... 44

Figure 1-14: Online Survey (Q11) - Organizations’ Understanding of Partner Skills/Knowledge

..................................................................................................................................................... 50

Figure 1-15: Online Survey (Q12) – Primary Means of Communication between Partners ...... 51

Figure 2-1: Washington County, Size by In-degree Centrality .................................................... 55

Figure 2-2: Washington County, Betweenness by Sector ........................................................... 59

Figure 2-3: Distribution of network organizations in Washington County ................................. 61

Figure 2-4: Reciprocal Connections in Washington County ........................................................ 63

Figure 2-5: Online Survey (Q3) – Survey Respondent Job Titles in Washington County ........... 68

Figure 2-6: Online Survey (Q6) – Organization Focus: Healthcare Awareness or Service Delivery

..................................................................................................................................................... 69

Figure 2-7: Online Survey (Q11) - Organizations’ Understanding of Partner Skills/Knowledge 74

Figure 2-8: Online Survey (Q12) – Primary Means of Communication between Partners ........ 75

Figure 3-1: Western MD, Size by In-degree Centrality ................................................................ 79

Figure 3-2: Western Maryland, Betweenness by Sector ............................................................. 82

Figure 3-3: Distribution of network organizations in Allegany and Garrett Counties ................ 84

Figure 3-4: Western Maryland Network – (Health Systems Organizations Only) ...................... 86

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Figure 3-5: Western Maryland Network, Excluding Health Systems .......................................... 87

Figure 3-6: Reciprocal Connections in Western Maryland.......................................................... 89

Figure 3-7: Online Survey (Q3) – Survey Respondent Job Titles in Allegany/Garrett Counties . 94


..................................................................................................................................................... 95


................................................................................................................................................... 101

Figure 3-10: Online Survey (Q12) – Primary Means of Communication between Partners .... 102

Figure 4-1: Lower Shore, Size by In-degree Centrality .............................................................. 106

Figure 4-2: Lower Shore, Betweenness by Sector ..................................................................... 109

Figure 4-3: Distribution of Network Organizations, Lower Shore ............................................. 111

Figure 4-4: Government Agencies in the Lower Shore network ............................................... 112

Figure 4-5: Reciprocal Linkages in the Lower Shore Network .................................................. 113

Figure 4-6: Online Survey (Q3) – Survey Respondent Job Titles, Lower Shore ........................ 118


................................................................................................................................................... 119


................................................................................................................................................... 124


Figure 5-1: Caroline & Dorchester Counties, size by in-degree centrality ................................ 129

Figure 5-2: Caroline & Dorchester Counties, Betweenness by Sector ...................................... 132

Figure 5-3: Distribution of network organizations in Caroline and Dorchester Counties ........ 134

Figure 5-4: Caroline & Dorchester Counties, Excluding Nonprofit & Community Organizations

................................................................................................................................................... 136

Figure 5-5: Online Survey (Q3) – Survey Respondent Job Titles in Caroline/Dorchester Counties

................................................................................................................................................... 142


................................................................................................................................................... 143


................................................................................................................................................... 148


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Social Network Analysis Report – DHMH, CCDPC September 30, 2015 Schaefer Center for Public Policy | University of Baltimore Page 1

Social Network Analysis: Building Partnerships for Healthy Communities Maryland Department of Health and Mental Hygiene

EXECUTIVE SUMMARY

At the request of the Maryland Department of Health and Mental Hygiene (DHMH), the Schaefer Center for Public Policy at the University of Baltimore’s College of Public Affairs conducted a web-based survey of healthcare organizations in five Maryland communities, spanning nine counties. The purpose of the study was to conduct a social network analysis of those healthcare organizations and their connections to each other. Social network analysis (SNA) is a tool for uncovering and mapping relationships among actors within and across organizations and sectors. It can be used to assess strength, efficiency, and effectiveness of connections and it can reveal the means and direction of communication between actors. SNA is also used to examine the structure of network relationships, gauging the extent of connections among participants, the resilience of the network as a whole, and the efficiency of information and resource exchange within the network. The primary focus of the research team was to use social network analysis to determine how well people and organizations in the counties worked towards a common goal; the degree of coordination and collaboration among healthcare organizations; and the rate and means of communication among them. Using these techniques, researchers were able to identify key sources of information and resources in each network and make recommendations to improve function across organizations in each of the five networks. Overall, the primary goal of the research is to understand the healthcare networks in each community, how those networks operate, and the strength of those networks.

SOCIAL NETWORK ANALYSIS: KEY MEASURES

Analysis of each network incorporates two modes – quantitative analysis of network characteristics and visualization of each network. Quantitative analytic measures include:

Density – the proportion of actual versus all possible ties within a network. This is a measure of how well connected the network is as a whole.

Degree Centrality – the number of connections each organization has to others in the network. In-degree (incoming connections) and out-degree (outgoing connections) may be discovered. These identify important sources of information or resources on the one hand, and the drivers of the network – those who push information or resources out – on the other.

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Betweenness Centrality – this is used to discover organizations that lie along the shortest path between any two other organizations. Organizations like these play an important role in disseminating information or resources throughout a network. In particular, they often serve as “bridges” connecting otherwise distant parts of the network, and as such, they can help improve the flow of communications.

Visualizing the Networks Network visualizations show organizational connections in a diagram, with organizations as dots (nodes) connected to others by a series of lines (vertices). A network visualization gives a graphic depiction of the measures listed above and can be a useful way to get an overview of the network, and for presenting the analysis in a more immediate and intuitive manner.

FINDINGS

Presented below are key findings from the study. Additional findings and analyses are presented in the each county’s section of the report.

BALTIMORE CITY

Baltimore City is the largest of the networks in the study, consisting of 287 organizations connected by 2,012 links. It is also the least densely-connected network. One of the central goals for growing this network will be to increase density without straining the capacity of organizations in the network. There are several large organizations operating in Baltimore City, among them the City health department, state health department, and the Johns Hopkins University and Medical systems. However, the largest bloc consists of community and philanthropic organizations, making up one third of the entire network. Assessing intersectoral connections and growing intersectoral communication and collaboration may also lead to gains throughout the network. Finally, while there is a strongly connected core to the network, there are a large number of peripheral organizations only weakly connected to the body of the network. Many of these are one-way connections, and lead from the core to the periphery. Developing these into reciprocal connections with partner organizations will improve collaboration; growing lateral connections between similar peripheral organizations will increase density and stability.\

WASHINGTON COUNTY

The Washington County network consists of 381 connections binding together 99 partner organizations. Healthcare systems make up one third of this network. Among these, divisions of Meritus are dominant, both in numbers, and in measures of centrality. The network also has an

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unusually high level of participation from private businesses. This level of intersectoral partnership is a strength for this network. One quarter of the network reports participating in a reciprocal connection with at least one partner organization, with the county health department most heavily involved in these types of partnerships. This degree of collaboration across sectors is an asset to this network, providing the basis for the continual development of strong collaborative partnerships.

WESTERN MARYLAND

The Western Maryland network is composed of 58 organizations across Allegany and Garrett counties, bound by 338 connections. It is the most densely connected network in the study; it also has the lowest proportion of weakly connected organizations among all networks. The network is dominated by health systems organizations, making up nearly half of the network. However, the robustness of connections throughout the network keep this from hindering connections between organizations or sectors. The diverse roles in the network are reflected in centrality measures: while healthcare organizations are leaders in pushing information and resources out to the network, county health departments and affiliated organizations are the leading resources to which other organizations turn. An additional measure of collaboration may be seen in the level of reciprocal relationships. Over one third of the organizations are involved in reciprocal partnerships. However, there is little participation of private businesses in the network, presenting an avenue for growing the network.

LOWER SHORE

The Lower Shore network is made up of organizations in Somerset, Wicomico and Worcester counties. In all, 68 organizations reported 257 connections. While government agencies are the dominant sector – they make up one third of the network – they also represent a more diverse range of government organizations than seen in other networks, including parks and recreation, and fire departments in several communities. As may be expected, county health departments play a central role in connecting government agencies. Although the private sector is relatively well represented, private businesses are only weakly connected to the network. Encouraging more active collaboration with these partners may increase the stability of the network.

CAROLINE & DORCHESTER COUNTIES

Eighty-one organizations across Caroline and Dorchester counties reported 570 connections, making this the second most-densely connected network. However, this level of connectivity

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may be influenced by the high geographic centrality of this network – nearly all network organizations are located in either Caroline or Dorchester’s county seat. Growing the network out into these sparsely populated counties may prove challenging. Community and philanthropic organizations play a dominant role. They make up the largest bloc of organizations; they are also among the most centrally connected organizations. Leveraging those community connections may be a means of strengthening the network. Growing reciprocal partnerships may also strengthen the network. While 21 organizations – one quarter of the network – report a reciprocal partnership, these account for only 14% of all connections in the network. Growing reciprocal relationships, and strategic management to increase collaboration and the development of more ‘bridging’ organizations may improve the network.

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SOCIAL NETWORK ANALYSIS: SURVEY OVERVIEW

In order to conduct the social network analysis, the Schaefer Center created a database of key healthcare organizations and representatives in the five county networks. The primary mode of data collection was a web-based survey of healthcare representatives in the targeted communities. The initial goal was to contact these healthcare representatives and find out which organizations they worked with in terms of hypertension, diabetes, and heart health. Once the research team received the names of these organizations, they created a database of key healthcare providers and healthcare awareness organizations in each of the networks to examine for further study.

IDENTIFYING KEY HEALTHCARE ORGANIZATIONS

In order to identify key healthcare providers and healthcare awareness organizations for the study, snowball sampling was used to create a database of key providers in nine Maryland counties. Those nine counties were separated into the following networks: Network 1: Baltimore City Network 2: Washington County Network 3: Allegany and Garrett Counties Network 4: Somerset, Wicomico, and Worcester Counties Network 5: Caroline and Dorchester Counties To start the data gathering process, the Schaefer Center contacted DHMH staff members in each of the five networks and asked them to provide a list of healthcare contacts/organizations that they work with to deliver healthcare or healthcare awareness. The first group of DHMH contacts were then asked to provide a list of organizations that they partnered with. Each time a new contact was identified, they were asked to provide a list of organizations that they worked with, and so on. This enabled the Schaefer Center to create a database of key organizations, whose members were contacted and given the main survey via e-mail. Once healthcare organizations responded to the main survey, researchers used that survey data as a foundation for the Social Network Analysis of each network.

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SURVEY DATA COLLECTION

Table 1 below lists each survey type, the information it was used to gather, and how the information was used in the SNA study. Table 1: Data Collection Methods

Type Key Elements How Utilized in the Study

Snowball Sampling Started with 15 DHMH contacts in 9 counties

Contact made via e-mail and phone

Resulted in 1,011 separate points of contact

Identified nearly 700 healthcare leaders

Identification of key healthcare leaders and organizations

Helped researchers assess the size and extent of each network

Provided the sample set of organizations contacted for the online survey

Online Survey 668 unique recipients received the survey

Data recorded relating to nearly 600 organizations

Results used to calculate the strength of each network

Input for the SNA model

Used to create a network visualization for each county that shows a diagram of all organizations and their connections to each other

Used for qualitative and quantitative analysis of critical network measures such as organizational ties, bridge organizations, and structural gaps in each network

A copy of the snowball sample query letter, which was e-mailed to all potential respondents, can be found in Appendix A.

SNOWBALL SAMPLING RESULTS

Started with 15 contacts in nine counties -- ended with 1,011 points of contact in the 5 networks:

Network 1: Baltimore City (486)

Network 2: Washington County (185)

Network 3: Allegany and Garrett Counties (73)

Network 4: Somerset, Wicomico, and Worcester Counties (126)

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Network 5: Caroline and Dorchester Counties (141)

Total number of healthcare leaders identified: 668 Total number of healthcare organizations identified: 593 Once the snowball sample was complete, the data was used to create a panel – a list of healthcare providers and healthcare awareness organizations which would then receive the main, online survey.

ONLINE SURVEY

The online survey was designed to assess the types of and quality of connections between the organizations in each network. It was comprised of 12 questions divided into three sections and administered via the web using the Qualtrics survey platform. To ensure data integrity, each potential participant was e-mailed a unique link to the survey. The online survey gathered responses in three main areas: information about the respondents’ organization; selection of the specific organizations that they work with; and qualitative information about their relationships with the organizations they selected.

Section 1 asked respondents to answer the following demographic questions about where they worked:

The organization’s name

Their department/division

Job title

Business sector of the organization

Organization type

Whether the organization was a Diabetes Program Partner (DPP)

Whether they delivered healthcare services or developed healthcare awareness. Section 2 asked respondents to view a list of healthcare organizations in their area, and select the organizations that they work with. This list was comprised of healthcare organization names that were gathered in the initial snowball sample. List networks and number of orgs? Section 3 asked respondents to select multiple-choice answers that accurately described their relationship with the organizations that they previously selected. These questions dealt with:

Nature of the relationship with each partner organization in terms of upstream/downstream referrals

Length of their working relationship with each organization

Frequency with which they communicate

Their understanding of the skills and knowledge of each partner organization

Primary means of contact between each organizations (phone, e-mail, in-person meetings)

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A complete copy of the online survey can be viewed in Appendix B.

ONLINE SURVEY RESPONSE RATES

While response rates for online surveys average between 15 and 20%, the overall response rate for this study was 59%. Data included all survey responses, the data from the snowball sample, plus data from respondents who did not finish the entire online survey, but completed the section about organizations they partner with. In other words, the research team used 100% of the organizations to create the network, and a full 59% of those organizations provided data about how they work with other organizations in their network. All of the survey completion rates are listed by County Network in Figure 1, followed by a complete summary of survey recipients, organizations, and response rates in Table 2. Figure 1: Online Survey Response Rates by Network

Network Key: 1: Baltimore City; 2: Washington County; 3: Allegany and Garrett Counties; 4: Somerset, Wicomico, and Worcester Counties; 5: Caroline and Dorchester Counties.

58% 57%63%

58%63%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

1 2 3 4 5

Online Survey Response Rates by Network

Coverage Rate

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Table 2: Online Survey Response Data

Network Organizations Responses Survey Response

Recipients Rate

1 288 195 337 58%

2 99 59 104 57%

3 58 41 65 63%

4 67 46 79 58%

5 81 52 83 63%

Total 593 393 668 59%

Network Key: 1: Baltimore City; 2: Washington County; 3: Allegany and Garrett Counties; 4: Somerset, Wicomico, and Worcester Counties; 5: Caroline and Dorchester Counties.

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INTRODUCTION TO SOCIAL NETWORK ANALYSIS

Social network analysis is a tool for uncovering and mapping relationships among actors within and across organizations and sectors. It can be used to assess strength, efficiency, and effectiveness of connections as well as to reveal the means and direction of communication between actors. Social network analysis is also used to examine the following:

Structure of network relationships

Gauge the extent of connections among partner organizations

The resilience of the network as a whole

The efficiency of information within the network

Resource exchange within the network As such, social network analysis is a useful way of exploring how well people and organizations work towards a common goal. Social network analysis focuses directly on the relationships between actors (who may be either individuals or organizations), rather than the qualities of discrete actors. This relational data can be presented graphically and analyzed using a number of statistical methods. At its simplest, a network is simply a description of the connection (“link”) between two or more actors (“nodes”). Network connections can be depicted in a matrix, as in Table 3 below. These matrices form the basis for quantitative analysis of relationships between nodes.

SOCIAL NETWORK ANALYSIS: AN EXAMPLE

Table 3: Sample Network Matrix

Andre Beverly Carol Diane Ed Fernando Garth Heather Ike Jane

Andre 0 1 1 1 0 1 0 0 0 0

Beverly 1 0 0 1 1 0 1 0 0 0

Carol 0 0 0 1 1 1 0 0 0 0

Diane 0 0 0 0 1 1 1 0 0 0

Ed 0 0 0 0 0 0 1 0 0 0

Fernando 0 0 0 0 0 0 1 1 0 0

Garth 0 0 0 0 0 0 0 1 0 0

Heather 0 0 0 0 0 0 0 0 1 0

Ike 0 0 0 0 0 0 0 0 0 1

Jane 0 0 0 0 0 0 0 0 0 0

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In this network, Andre reports relationships with Beverly, Carol, Diane, and Fernando (these are represented by the “1’s” shaded in light green). But Andre does not have a relationship with Ed, Garth, Heather, Ike or Jane (these are marked as “0” in Andre’s row). Note that while Beverly also reports a relationship with Andre (shaded yellow), the others do not (shaded light red). This means that Andre’s links to Carol, Diane, and Fernando are each uni-directional. They only go in one direction, from Andre to the others. However, Andre’s link to Beverly is reciprocal – he reports a relationship with her (the “1” in bold and shaded green), and she reports a relationship with him (the “1” shaded yellow).

SOCIAL NETWORK ANALYSIS IN SOCIAL SETTINGS

The nature of these relationships depends on the type of network being examined. In a casual social setting, it may mean that Andre reports that he is friends with Carol, but Carol doesn’t feel that she is friends with Andre. In an organizational setting, it may mean that Andre sends information or resources to Carol, but that Carol doesn’t send information or resources back to Andre. Depending on the nature of the work relationship between Andre and Carol, this may be entirely appropriate. However, in many situations, it may be advantageous to close the loop by having Carol report back to Andre.

CREATING A NETWORK VISUALIZATION

Additionally, a variety of information about networks may also be communicated through a graphical depiction of the network. One way of depicting this sample network is shown in Figure 2.

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Figure 2: Visualization of Sample Network

Figure 2 shows the connections between actors in the sample network and, through color-coding, gives some basic information about those actors. That is, they are driven by the connections between nodes. Thus, it may be tempting to conclude that Diane is the most important person in this network, based on her position. However, networks are relational, not positional – Diane’s position at the center of this network is a function of the analytic software laying connections out for visual clarity. Network analysis assesses importance in terms of the qualities of connections between nodes. A variety of measures of ‘importance’, referred to as ‘centrality’ can be utilized to better understand the nature of relationships between nodes.

VISUALIZING THE NETWORK WITH INCOMING CONNECTIONS

For example, Figure 3 below shows the sample network drawn by proportion of in-coming connections. The positions of the actors have not changed; the relative size of each node now reflects the number of in-coming connections – in this case, the number of people that report being friends with a particular person. As may be seen, Garth is the most popular, with four people claiming him as a friend, followed by Fernando and Diane.

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Figure 3: Sample Network, in-degree centrality

This measure of ‘popularity’ will be an important measure for local healthcare networks, as it reflects how many organizations report working with a particular agency. Bear in mind that increasing this measure of ‘popularity’, or other network measures, may not lead to greater effectiveness. Raising an organization’s number of incoming connections beyond their capacity to handle the information or work coming from additional connections may simply overwhelm an organization. Rather, understanding the workload, capacity, and expectations of each organization is key to effective management of the network.

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VISUALIZING THE NETWORK WITH OUTGOING CONNECTIONS

Figure 4 below presents an alternative way of looking at this network, ranking nodes by their outgoing connections. In this case, the figure emphasizes Andre and Beverly as the most outgoing people in the network. Because they have so many outgoing connections, they are effective means of spreading information quickly throughout the network. Figure 4: Sample Network, out-degree centrality

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BETWEENNESS (GROUPS THAT ACT AS BRIDGES TO OTHERS)

One additional perspective on viewing networks is worth introducing here. Betweenness assesses how frequently a given node lies along the shortest path between two other nodes. Because information and resources are assumed to flow best along the quickest route, those nodes that facilitate quick communication play an important role. Figure 5: Sample Network, betweenness centrality

In addition, betweenness emphasizes a bridging role – those nodes that serve to connect different parts of the network. As may be seen in Figure 5 above, Heather plays an important bridging role – she is the only path connecting Ike and Jane to the rest of the network. There are redundant connections throughout the main body of the network; if anyone in the main body of the network left, it would still be possible to move from any node to any other node. However, if Heather leaves, Ike and Jane will be lost to the network as well. Here, too, identifying these bridging organizations can lead to more effective network management. Data about these connections are gathered from surveys of network actors and can be assessed on a variety of measures. For this healthcare study, the network consists of organizations in government, non-profit and private sectors that collaborate on increasing awareness of, and

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delivering services to treat, chronic disease. Information on the survey and network measures may be found below.

SOCIAL NETWORK ANALYSIS: KEY CONCEPTS

Network analysis quantifies relations between nodes in order to identify the structure of networks; reveal patterns of communication and exchange; and assess network robustness, strengths, and weaknesses; and, recommend strategies for increasing network efficiencies. NodeXL (Smith et al., 2010) was used to analyze survey responses, calculate network metrics, and generate network graphs.

NETWORK COMPOSITION

Networks are composed of two elements: the actors (individuals or organizations) working within a network, known as ‘nodes’, and the connections between those nodes, called ‘links’. The structure of a social network – its layout or pattern – is not fixed, but depends on the connections between the actors in a network. Understanding the qualities of these connections is critical to efficient management of a network, and for effective collaboration among network partners. Network analysis uncovers information about the qualities of links in a network. It also addresses a basic question: “Which are the important nodes?”. To answer this question, network analysis proceeds from two fundamental points. First, there are a variety of ways of being important. Second, ‘importance’ is connected to ‘centrality’ – how close a given node is to the center of a network. By this, network analysts are really asking “how close to the center of relationships is a particular node?”. Because network structure is not fixed, the center is also not fixed; it may change based on changes in the links forming the network. The center may also shift depending on which qualities of linkages are being examined. Of relevance to this report are measures of degree and betweenness centrality.

DENSITY

Network density is a measure of completeness: it counts the number of connections in a network and displays that total as a fraction of all of the possible connections within that network. It is a very basic metric that can provide a general sense of how well-connected a network is. Other measures provide more insight by assessing various qualities of the connections that do exist. Note that higher density is not always better, particularly above a certain level. To illustrate, imagine your contacts file as a network. Consider the impact on that network if each of those

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contacts was in regular communication with every other contact. Although low density can lead to poor information or resource transfer and runs the risk of network dissolution, high density can overwhelm individual nodes and bring a network to a halt.

DEGREE CENTRALITY

Degree centrality is simply the total count of links connecting a given node to the rest of the network. This may be thought of as roughly analogous to popularity; it measures the volume of connections for each node. A high degree centrality indicates one measure of importance; it also signals particular management requirements. Nodes with high degree centrality are more connected. This means that they can more efficiently facilitate the flow of information and resources throughout a network. It also means that the volume of flow may overwhelm a node’s capacity. Consider an airport with high degree centrality, such as Newark or Atlanta. The domestic air network relies on these, and other hub airports, to move a large volume of passengers and freight. However, the high volume increases the complexity of operations at these airports. Additionally, the impact of a slowdown or shutdown of these hubs has a proportionally large effect on the whole network.

DIRECTION OF CONNECTIONS

Degree centrality may be further distinguished by the direction of connections. In figure 1, all nodes appear to have a degree of two. However, Carol shows three links, two incoming, and one outgoing. In-degree centrality measures the number of connections coming into each node, while out-degree centrality measures the number of connections originating with a particular node and going out towards other nodes in the network. In-degree centrality reports how many other networks have a connection to a particular node. In this study, it ranks how many other nodes connect with a given node – how many organizations rely on a particular organization to help treat chronic disease. Those nodes may be important resources, providing information, support, or referrals. They may be the organizations to which partners turn. Conversely, out-degree assesses the degree to which a node pushes out information or resources to other organizations in the network.

BETWEENNESS CENTRALITY

Betweenness centrality is a measure of how often a given node sits on the shortest path between two other nodes. The underlying assumption is that information, resources, etc. will flow through the most direct path possible. Therefore, a node that lies on the shortest route will be included in more transactions and more information, resources, etc. will be available to it as a result. Nodes with high betweenness centrality can serve several important functions.

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First, they may be thought of as clearinghouses, moving information or resources between a large number of nodes in a network. Second, they may serve as bridges – they may be one of only a few, or the only, connection between otherwise distant or unconnected parts of a network. In this context, they are central to the cohesion of the network as a whole. One implication of betweenness centrality is the impact of a node’s absence on the network – the extent to which removing a particular node would disrupt communication between other nodes, or disconnect them from the network entirely. Finally, nodes connecting distant parts of a network often serve a valuable function of spreading information not otherwise readily available to a set of nodes. These ‘weak ties’ bring new information in and can significantly affect how nodes make use of the information and resources at their disposal. Consider, for example, the serendipity that can result from contacts at an outside agency, or from friend-of-a-friend connections.

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BALTIMORE CITY: SOCIAL NETWORK ANALYSIS RESULTS

RESPONSE RATE

Ideally, network analysis will proceed from complete data. However, this is unusual to achieve in practice. The snowball sample identified 287 organizations, or divisions within organizations, and 337 recipients received the survey. Of that total, 195 responses were received. Partial data on the non-respondents was obtained from those completed surveys.

HEALTHCARE ORGANIZATION SECTORS

Table 1-1 shows the 287 organizations in the network, categorized by CDC sector. Where conceptual overlap between sectors was encountered, organizations were categorized as follows:

Business and health system (e.g. private medical practice) – counted as health system

Government and education (e.g. public school; Board of Education) – counted as government

Nonprofit organizations not operating as a health system were categorized as philanthropies.

Note: All network diagrams will use the colors below to represent their sector. Table 1-1: Organization Totals by Sector

Sector Number of

Organizations

Business 23

Government 55

Health System 62

Education 37

Community 27

Philanthropy 83

Total organizations/divisions in network

287

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NETWORK DATA

DENSITY

The 287 organizations reported a total of 2,012 connections. In a network this size, there are 82,082 possible connections. The density of this network is .025. Overall, the network is not highly interconnected. As the visualization of the Baltimore network shows in Figure 1-1 below, there is a dense web of connections at the core of the network. However, the majority of nodes are only loosely connected to the network.

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Figure 1-1: Baltimore City – Network Visualization

These connections may indicate that the network connects organizations that otherwise would not work together; it may also be a point of attention in the management of the network, as some strategic monitoring may decrease the loss of any such weakly connected nodes or sections.

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DEGREE CENTRALITY

Two measures of degree centrality were obtained. In-degree centrality is the count of all nodes in a network reporting a link to a particular node. Table 1-2 presents the most central organizations by in-degree count. In other words, the table lists organizations by how connected they are to other organizations. By this measure, the American Heart Association is the most central organization, with 46 other organizations (approximately 17% of the entire network) reporting a connection to the AHA. For this study, the survey asked organizations to identify all partners “with which your organization worked on any of the following: hypertension, diabetes, blood pressure, weight management, or heart health initiatives.” Table 1-2: Organization Totals by Sector In-degree Centrality, Baltimore City

Organization Centrality

American Heart Association 46

Baltimore City Health Department 41

Maryland Department of Health (DHMH) 37

American Diabetes Association 37

Johns Hopkins - Bloomberg School of Public Health 34

Baltimore City - Department of Health - Office of Chronic Disease Prevention 28

Y of Central Maryland - Community Relations 26

American Heart Association - Cooking with Heart Kitchen 24

Maryland Department of Health - Chronic Disease Prevention and Control 24

Bon Secours - West Baltimore Health Enterprise Zone 24

Total Health Care, Inc. - Community Programs 24

Baltimore City - Office of Aging & Care Services 23

Baltimore City Health Department - B'more for Healthy Babies 23

MedStar Health and Hospital System 22

Morgan State University 22

Coppin State University 21

Baltimore City Health Department - Maternal and Child Health 21

American Cancer Society 21

Zeta Center Healthy Aging Partnership (Z-HAP) 21

Note: A full listing of all organization in this network, along with in-degree, out-degree, and betweenness centrality scores, may be found in Appendix C.

As may be seen in Table 1-2 above, in-degree centrality falls quickly. In-degree centrality falls by 50% over the course of the top 19 organizations – from the AHA at 46 down to Z-HAP at 21. Only 74 organizations in Baltimore City have an in-degree centrality of 10 or higher.

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At the low end of the scale, 26 organizations report zero in-coming connections; and of that group, 14 report out-going connections to other organizations. While this is a relatively small percentage of the whole network, closer examination reveals an opportunity to improve network robustness. Table 1-3, below, lists the 14 organizations with zero in-degree and some out-degree connections. In particular, the strong out-degree centrality of community-related programs with zero reported in-coming connections may indicate a need to close the loop by encouraging community partners to communicate more effectively with the community relations organizations listed here. Table 1-3: Organizations with Out-Degree, but No In-Degree Centrality

Organization In-degree

count Out-degree

count

Baltimore City Health Department - Community Relations 0 94

American Diabetes Association - Community Outreach 0 53

Johns Hopkins - Community and Global Programs 0 52

Y of Central Maryland 0 50

MedStar Franklin Square Medical Center 0 26

Moveable Feast - Nutrition Services 0 22

Center for Grace-Full Living - Amazing Grace Evangelical Church 0 22

Baltimore City Health Department - Youth Health 0 13

Johns Hopkins AIDS Education and Training Center 0 12

MedStar Good Samaritan Hospital - Community Outreach 0 10

MedStar Good Samaritan Hospital 0 7

Total Health Care, Inc. 0 6

DHMH Comprehensive Cancer Control Program 0 5

MedStar Harbor Hospital 0 2


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OUT-DEGREE CENTRALITY

Organizations with the highest out-degree centrality are presented in Table 1-4 below. As the table shows, the Baltimore City Health Department’s Office of Community Relations is the most central outwardly connected organization. It has connections with roughly 1/3 of the network. As with in-degree centrality, the number of connections falls quickly, with only 60 organizations reporting more than 10 outgoing connections. A significant portion of the network reports no outgoing connections, although meaningful conclusions cannot be drawn, as non-responding organizations present as zero outgoing connections. Table 1-4: Out-Degree Centrality, Baltimore City

Organization Out-degree

count

Baltimore City Health Department - Community Relations 94

Maryland Hunger Solutions 92



Zeta Center Healthy Aging Partnership (Z-HAP) 61

James Long Fitness 61

University of Maryland Extension 59

Total Health Care, Inc. - Community Programs 57

Bon Secours - West Baltimore Health Enterprise Zone 53

Baltimore City Health Department - B'more for Healthy Babies 53

Johns Hopkins - Community and Global Programs 52

MDQuit Tobacco Resource Center 51

Johns Hopkins - Bloomberg School of Public Health 50

Y of Central Maryland 50

Central Baptist Church 45


Figure 1-2 on the following page shows all 287 organizations collaborating in the Baltimore City network as well as all connections reported between these partners. In this figure, node size increases with in-degree centrality – as more organizations report working with a particular partner, that node increases in size in this figure.

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Figure 1-2: Baltimore City, Node Size by In-Degree Centrality

Because the Baltimore City network is so large, it can be difficult to observe relationships due to the density of the graphics. Figure 1-3 on the next page shows a partial and less-dense network. Only those nodes with eight or more in-coming connections are shown.

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Figure 1-3: Baltimore City, In-Degree Count of 7 or Higher

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BETWEENNESS CENTRALITY (BRIDGE ORGANIZATIONS)

Betweenness centrality assesses how frequently a given node lies along the shortest path between any two other nodes in the network. Betweenness tends to identify nodes that serve as ‘bridges’ connecting clusters within a community. These bridges are particularly important, as they bring a network closer together and disseminate information to parts of a network that may be otherwise distant from one another. Betweenness, as calculated in Node XL, often follows a power law, so it tends to drop very quickly, and is a normal feature of networks. Put simply, networks seek to work through ‘hubs’ – nodes with high betweenness. An important consideration for network management is to identify which nodes serve as such hubs and to ensure that they have sufficient capacity to handle the load of information flowing through them. Table 1-5 below presents the organizations with the highest betweenness centrality in Baltimore City’s network. Table 1-5: Betweenness Centrality, Baltimore City

Organization Betweenness

Baltimore City Health Department - Community Relations 7995.081

Maryland Hunger Solutions 7056.278

American Diabetes Association 7026.511

American Heart Association 5438.999

Johns Hopkins - Community and Global Programs 4210.666

Johns Hopkins - Bloomberg School of Public Health 4004.001

Zeta Center Healthy Aging Partnership (Z-HAP) 3350.614

James Long Fitness 3151.394

University of Maryland Extension 3125.039

Baltimore City Health Department - B'more for Healthy Babies 3119.361

MDQuit Tobacco Resource Center 3115.362

Total Health Care, Inc. - Community Programs 2686.378

Baltimore City Health Department 2502.670

University of Maryland Medical Center 2207.931

Bon Secours - West Baltimore Health Enterprise Zone 2082.892


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Figure 1-4 below shows the Baltimore City network, with nodes sized by betweenness centrality. For clarity, the figure shows a simplified depiction of the network, excluding outlying nodes. Figure 1-4: Baltimore City, Betweenness by Sector

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NETWORK GEOGRAPHICS

MAPPING OUT THE LOCATIONS OF HEALTHCARE ORGANIZATIONS IN BALTIMORE CITY

Figure 1-5, on the following page, shows the geographical distribution of network organizations within Baltimore City. Each red dot in the figure marks the address of at least one network organization. Note that any organizations with an address outside of the city limits is not shown; also, that any organizations sharing the same address will only be marked by a single dot. Thus, 63 network partners located outside the city are not shown. Additionally, duplicate addresses comprise a significant portion of the network. These are primarily concentrated among large organizations, including divisions of the City Health Department, the State Department of Health and Mental Hygiene, and arms of Johns Hopkins. However, a good sense of the distribution of network partners throughout the city can readily be made. Many of the organizations in the Baltimore network are large organizations with a state, regional, or national scope. These may be expected to serve clients across the city. However, there are also a significant number of local and community organizations that play a key role in the health of the network, and in delivering services, information, and resources to citizens. Although the dots of the Baltimore City Map do not differentiate among these types of organizations, the concentration of organizations located in Central and Western Baltimore is striking. Future development of the network will include strategic assessment to better understand this distribution as well as to identify communities most in need of services in Southern, Eastern and Northern Baltimore and to develop a plan to grow the network in those regions of the city.

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Figure 1-5: Distribution of Healthcare Organizations in Baltimore City

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BALTIMORE CITY: DISCUSSION & RECOMMENDATIONS

Baltimore City’s network consists of 287 discrete nodes bound together by 2,102 linkages. As was previously shown in Table 1-1, nonprofit and community organizations make up the largest bloc, accounting for 1/3 of all nodes. Table 1-1’s count of organizations slightly masks the proliferation of nonprofit and community organizations in the network, as the next two largest blocs (health systems and government) each have significant clusters – several divisions within larger organizations. Notable among these are offices within the city health department and divisions of the Johns Hopkins University and Hospital systems. These clusters will be examined in greater detail below. One of the challenges for managing this network, and maintaining healthy collaborations, will be to partner effectively both with these large regional and national organizations as well as with much smaller, community-based organizations. Facilitating clear communication and effective coordination between organizations of such different scope, size and resources, will require careful attention to each organization’s needs and capacities. This challenge is reflected in the network’s density. Although the largest network, it is the least dense. Density is the proportion of reported connections to all possible connections. While a fully connected network is not desirable – it would likely be overwhelming to participants – the low density in this network indicates the potential to grow collaboration by increasing lateral connections between organizations. The low density may be seen in Figure 1-1, in the outer ring of organizations only weakly connected to the network.

RECIPROCAL RELATIONSHIPS

Another perspective on this may be gained by examining only those reciprocated connections – those cases where each partner reports a mutual connection with another. Those connections are shown in Figure 1-6 on the following page.

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Figure 1-6: Baltimore City, Reciprocal Connections

As may be seen in the figure above, 39 organizations are involved in 146 reciprocal connections. These mutually-acknowledged partnerships account for only 14% of all organizations and 7% of all connections in the network. Efforts to increase reciprocal relationships should strengthen the network and bring significant increases in efficiency and effectiveness. This may particularly valuable for smaller organizations with limited capacity and resources. Strategies for increasing reciprocal connections should focus not only on growing new connections, but fostering an awareness of mutual partnerships that may already exist but were not acknowledged as such by one partner. In other words, making network organizations conscious of their partners, as well as of potential new partners, should yield valuable results.

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CLUSTERED ORGANIZATIONS WITHIN BALTIMORE CITY

Multiple departments of the Baltimore City Health Department (BCHD) and the Maryland Department of Health and Mental Hygiene (DHMH) were reported as unique nodes in this network, as were various divisions of the Johns Hopkins University and Hospital systems. Figure 1-10 groups divisions of each of those large umbrella organizations into a single node, showing the dominance of these three organizations in the network. In the figure, Johns Hopkins is the large red cluster node, DHMH is the dark blue cluster node, and BCHD is the light blue cluster node. Another means of assessing the impact of these three larger organizations on the network is to remove them from the network, as is shown in figure 1-7 on the next page.

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Figure 1-7: Baltimore City, Large Organizations Grouped Together

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Figure 1-8: Baltimore City, Large Organizations Removed

As seen in the figure above, the overall network becomes less dense, and the number of weakly connected nodes rises slightly. However, only a few nodes are disconnected from the network. Interestingly, the two most central organizations remaining are the American Heart Association and the American Diabetes Association – the two large dark green nodes in the lower center of Figure 1-8, above. While these are important partners in the fight against chronic disease, they are also large national organizations. To examine the structure of local partners in the network, Figure 1-9 on the following page shows the Baltimore City network with these two organizations also removed.

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Figure 1-9: Baltimore City: No Cluster Organizations, American Heart Association or American Diabetes Association

As the default view, Figure 1-9 sizes nodes by in-degree centrality, emphasizing the number of incoming connections to that node. As so many connections have been eliminated with the removal of large resource-rich organizations, the role of passing information among the remaining nodes becomes more significant.

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Figure 1-10 shows the same portion of the Baltimore City network as in the previous figure, but ranks the nodes by betweenness centrality, emphasizing those nodes that play a connecting role between other organizations in the network. The most central such nodes have been labeled in the figure. Figure 1-10: Partial Baltimore City Network by Betweenness Centrality

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LEVERAGE OPPORTUNITIES ARISING FROM THIS STUDY

Basic benefits from the fundamental act of mapping the network should not be overlooked. These include:

NETWORK EVALUATION

The size and composition of the network is now overt. In addition to recommendations made here, local health officials can undertake their own evaluation of how well suited the current partnerships are towards advancing the goals of chronic disease prevention. Strategic planning to incorporate new organizations into the network, or shift the capacity, centrality, or role of existing partners, can be made.

PARTNER AAWARENESS

Partner organizations are now aware that they are part of a larger network. The view from the ground is necessarily constrained and often focused closely on an individual organization’s specific mission and focus. Participation in the survey made respondents aware that they are part of a larger network, and presents an opportunity to strengthen and grow the network.

Disseminate a list of network partners throughout the network. Doing so encourages increased communication and collaboration among partner organizations. Discussion with some respondents revealed the existence of local partners in the neighborhood that were unknown to the respondent. Collecting and publishing basic information on the partner organizations is an easy way to more fully inform the network as to who everyone is and what they are doing; may cut down on redundancies; and, can lead to the growth of lateral connections between partner organizations.

Develop a communication forum for the network. A formal publication, either in print or online, may suffice. An open forum, such as a discussion board, email listserv or wiki, facilitates two-way communication among participating organizations. A combination of centralized distribution (e.g. newsletter or email blast) to push significant milestones, achievements, or updates to the network, along with maintenance of a discussion forum for network-wide input, may be desirable.

Develop a strategy for managing clusters within the network. These may be based on geography, service provision, mission focus, or some other relevant characteristic. As noted above, at least some organizations in a neighborhood were unaware of nearby network partners. Additionally, organizations dispersed across the network may not be aware of all other similar partner organizations. This may be particularly apt for community organizations working within a specific area and serving a focused population.

Developing awareness of the network and acknowledging participation may be particularly important for smaller and community-oriented organizations on the

________________________________________________________________________________________________________


periphery of the network. Many of these organizations are only weakly connected to the network, and may benefit not only from increased connections, but from increased recognition as well. Several respondents from small organizations expressed sentiments of inferiority: A perception that ‘the real work’ is being done by larger, more central organizations; that the flow of communication is largely ‘outward’ from those large central organizations; and, that more recognition of the needs and accomplishments of small peripheral organizations is needed.

ENCOURAGE THE GROWTH OF LATERAL CONNECTIONS ON THE PERIPHERY

The previous point addressed relations between central and peripheral organizations. Relationships among peripheral organizations, particularly those sharing a set of common characteristics (size, audience, mission, etc.) have different needs and require a different management strategy. Capturing those organizations and their needs can be difficult. Some local organizations reported not being aware of organizational or contact names in the network. Convincing small organizations that their partnership is a valued contribution to the network can be challenging. Limited response rates from small organizations may be one indicator of this. That response rate limited analysis of the periphery and showed a higher level of uni-directional connections from the center to the periphery than may be the case in actuality. Put simply, it is to be expected that peripheral organizations have more ties than are shown. This is supported by discussion with some respondents from small peripheral organizations who report a strong sense of collaborative partnership with other such organizations. These relationships were described as frequent, consisting of collaborative back-and-forth, and multi-modal (email bolstered with calls and in-person meetings). Additionally, these collaborations were attributed in part to a lack of resources and a resultant need to work together for mutual success. To the extent possible, these collaborative partnerships should be acknowledged and encouraged.

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BALTIMORE CITY: SURVEY RESULTS AND KEY INFORMATION

SURVEY RESPONDENTS AND ORGANIZATIONS

The survey respondents represented a wide range of healthcare provider and awareness organizations in Baltimore City. Overall, 287 organizations in Baltimore City were contacted for the survey. Survey results show that a wide cross-section of organizations was represented. Examples of several key organizations include the following:

National organizations: American Heart Association, American Diabetes Association, American Lung Association

State and local government: Maryland Department of Health and Mental Hygiene (DHMH), Baltimore City Health Department

Major hospital/university systems: Johns Hopkins University, University of Maryland

Area universities: Morgan State, Coppin State

City government: Baltimore City Health Department

Insurance and Managed Care organizations: Amerigroup, Priority Partners MCO

SURVEY COMPLETION RATES FOR MAJOR ORGANIZATIONS

Using the survey results, researchers were able to determine which organizations in Baltimore City had the highest number of in-degree and out-degree centrality. In other words, these organizations had the highest number of incoming and outbound connections to others in the network and most of them completed the survey. The range goes as follows: 10 out of the top 10, 27 out of the top 30, and 42 out of the top 50 organizations all completed the survey. They also provided important information about their relationships with other, less well-connected organizations, providing the research team with a stronger view into how the Baltimore City Network operates.

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SURVEY QUESTIONS AND ANSWERS

Overall, the online survey was used to gather information about healthcare organizations in Baltimore City, find out who they partnered with, whether those organizations were in Baltimore City or elsewhere, and to collect quantitative and qualitative information about those relationships. The entire online survey can be viewed in Appendix B.

SECTION 1: BALTIMORE CITY HEALTH ORGANIZATIONS

Section 1 asked survey recipients several demographic questions about the organization they worked for. The questions asked for the following information:


The respondent’s particular division or department

The respondent’s job title



Whether their organization delivered healthcare services or developed healthcare awareness

QUESTIONS 1 AND 2: HEALTHCARE ORGANIZATIONS: NAMES/DIVISION/DEPARTMENT

Specifically, Questions 1 and 2 asked survey respondents to list their organization’s name and the department or division they worked in.

QUESTION 3: SURVEY RESPONDENTS’ JOB TITLES

Question 3 asked survey respondents to list their official job title. In Baltimore City, the survey was completed by a wide variety of decision makers with various job titles that referenced managerial or executive capacity. The most common job title was Director or Executive Director (36%). When including executives, organization founders, managers, and Deans/Professors, a full 57% of decision makers at high levels completed the survey for Baltimore City. All survey respondents’ job titles are listed by percentage in Figure 1-11 on the following page.

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Figure 1-11: Online Survey (Q3) – Survey Respondent Job Titles in Baltimore City

QUESTION 4: HEALTHCARE ORGANIZATIONS: BUSINESS SECTOR

Question 4 asked survey respondents to view seven business sector categories and choose which one best described their organization. The organization sectors were listed as follows: Government, Health System, Education/Academia, Community organization, Business, Philanthropy, or Diabetes Program Partner (DPP).

QUESTION 5: DIABETES PROGRAM PARTNERS (DPP)

The next question asked survey respondents to state whether their organization was a Diabetes Program Partner (DPP) or not. In Baltimore City, the majority of respondents (81%) said no. The remaining 19% said they were a DPP. Totals are listed in Figure 1-12 on the following page.

Other8%

Executive/Founder7%

Nurses/Nursing6%

Director/Executive Director

36%

Manager9%

Coordinator17%

Community-based12%

Dean/Professor5%

Survey Respondent Job Titles

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Figure 1-12: Online Survey (Q5) – Diabetes Program Partners

For Baltimore City, the organizations that identified themselves as Diabetes Program Partners (DPP) are listed below.

American Diabetes Association

Baltimore City Health Department

Black Nurses Association of Baltimore, Inc. (BNAB)

Delmarva Foundation

James Long – Coppin State fitness program

Johns Hopkins University – Bloomberg School of Public Health

Johns Hopkins Health System

Maryland State Department of Education

MedStar Good Samaritan Hospital

New Shiloh Baptist Church Nurse's Ministry

Saint Agnes Hospital

University of Maryland Medical System

Y of Central Maryland

Zeta Healthy Aging Partnership (Z-HAP)

No, 81%

Yes, 19%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Is your organization a Diabetes Program Partner (DPP)?

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QUESTION 6: HEALTHCARE ORGANIZATIONS: FOCUS

The last question in Section 1 asked respondents if their organization focused more on providing healthcare services or developing healthcare awareness with respect to hypertension, diabetes, or heart health. The Baltimore City results were a virtual tie, with 49% of survey respondents saying their focus was on healthcare provision or service delivery. The remaining 51% said they focused on developing awareness of chronic health issues. The answers about organization focus are represented in Figure 1-13 below. Figure 1-13: Online Survey (Q6) – Organization Focus: Healthcare Awareness/Service Delivery

SECTION 2: BALTIMORE CITY HEALTH ORGANIZATIONS: RELATIONSHIPS

Section 2 presented survey respondents with a list of healthcare organizations in Baltimore City and asked them to select the ones they partnered with.

QUESTION 7: HEALTHCARE ORGANIZATIONS’ FREQUENT PARTNERS

Question 7 asked survey respondents to view a list of healthcare organizations in Baltimore City and select the ones that they partnered with on various chronic health issues. This enabled the research team to compile of list of the most frequently selected healthcare organizations in the city, according to the survey respondents.

Developing awareness of

chronic disease, 51%

Providing healthcare

servicesfor chronic

disease,49%

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Does your organization focus more on...

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Table 1-6 below lists the Top 25 most frequently selected healthcare organizations in Baltimore City, ranked by the percentage of survey respondents who listed them as a partner. For example, the first entry on the list is the American Heart Association, with 53% – this means that a full 53% of the organizations surveyed said the American Heart Association was one of their partners. Table 1-6: The Top 25 Healthcare Organizations in Baltimore City (by % selected in the survey)

Organization % Selected

1. American Heart Association 53%

2. Baltimore City Health Department 47%

3. American Diabetes Association 43%

4. Maryland Department of Health (DHMH) 42%

5. Johns Hopkins – Bloomberg School of Public Health 40%

6. Baltimore City Health Department – Office of Chronic Disease Prevention 31%

7. Y of Central Maryland 30%

8. American Heart Association - Cooking with Heart Kitchen 28%

9. Maryland Department of Health (DHMH) Ctr. for Chronic Disease Prevention and Control

27%

10. Total Healthcare 27%

11. Bon Secours Health System 27%

12. Baltimore City Health Department – Office of Aging & Care Services 26%

13. Morgan State University 26%

14. B'more for Healthy Babies 26%

15. MedStar Health and Hospital System 26%

16. Baltimore City Health Department – Maternal & Child Health 24%

17. Coppin State University 23%

18. Zeta Healthy Aging Partnership (Z-HAP) 23%

19. American Cancer Society 23%

20. St. Agnes Hospital 21%

21. Health Care Access Maryland 21%

22. Bmore Fit 20%

23. Baltimore City Health Department – Baltimarket 19%

24. MD QUIT 19%

25. Chase Brexton 19%

The top 25 organizations listed above are very well-connected, so they are key organizations that serve the city, but there are several smaller organizations on the list that are well-connected despite their relatively smaller size. The Zeta Healthy Aging Partnership and Bmore Fit are two examples of this, and were the smallest organizations represented in the list above.

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RELIGIOUS ORGANIZATIONS IN BALTIMORE

The importance of religious organizations in Baltimore cannot be overstated. A full 11% of the organizations in the network are churches, parishes, ministries or affiliated with such. This rate is higher than the other networks in the study. While Baltimore’s large population means there will be more religious organizations, the ones in Baltimore are active in their communities and have a wide variety of events, programs, and initiatives.

SECTION 3: BALTIMORE CITY HEALTH ORGANIZATIONS: RELATIONSHIP QUALITY

Section 3 of the survey asked Baltimore City organizations about the type of relationships they had with the partner organizations they selected in Section 2. For every specific organization they selected, respondents were able to provide information about that partner with regard to upstream/downstream relationships, the length of their relationship, the frequency with which they communicated with partners, their understanding of their partners’ skills and knowledge, and finally, their primary means of communication with partners.

QUESTION 8: UPSTREAM AND DOWNSTREAM RELATIONSHIPS

After survey respondents selected the organizations they worked with, subsequent survey questions asked them to provide information about the nature of their relationship with those partners. The first question in Section 3 asked respondents to name which organizations gave them information (also known as an “upstream” relationship) and which organizations they sent information to (also known as a “downstream” relationship.) The list of the top organizations in Baltimore City in terms of having the most downstream partners is listed in Table 1-7. According to survey respondents, the organizations on this list are distributing information or providing referrals (downstream) to others on a frequent basis.

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Table 1-7: Organizations with the Highest Number of Downstream Partners

Organization # of Partners

1. American Diabetes Association 30

2. American Heart Association 26

3. Maryland Department of Health (DHMH) 16

4. American Heart Association - Cooking with Heart Kitchen 12

5. Baltimore City Health Department 12

6. Johns Hopkins - Bloomberg School of Public Health 11

7. American Cancer Society 10

8. Maryland Department of Health (DHMH) - Center for Chronic Disease Prevention Control

9

9. Baltimore City Health Department - Office of Chronic Disease Prevention

8

10. Baltimore City - Office of Aging & Care Services 8

QUESTION 9: LENGTH OF RELATIONSHIPS BETWEEN ORGANIZATIONS

Question 9 asked survey respondents about the length of the relationships with the organizations they named as partners. A scale with 5 options was presented, with “Less than 1 year” to define the briefest relationship, and “More than 10 years” to define the longest-lasting relationships. In Baltimore, survey respondents reported that the more established, larger health organizations were the ones they tended to have the longest relationships with. The organizations with the highest number of long-lasting relationships are listed in Table 1-8 below.

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Organization # of

Relationships






6. Maryland Department of Education - School Health Services 9


8. Maryland Department of Health (DHMH) - CCDPC 8

9. Maryland Department of Health (DHMH) - Ctr. for Tobacco Prevention, Ctrl.

8

10. American Lung Association 8

11. St. Agnes Hospital 7

12. Maryland Department of Health (DHMH) - Office of School Health 7

13. Johns Hopkins - School of Nursing 6

14. University of Maryland 6

15. Bon Secours Health System 6

QUESTION 10: FREQUENCY OF COMMUNICATION BETWEEN ORGANIZATIONS

Question 10 asked survey respondents how often they communicated with other organizations in their network. A scale with 4 options was presented, with “Frequently” to define the highest level of contact, followed by “Sometimes,” “Seldom,” or “Never” to describe less frequent levels of contact. In Baltimore, survey respondents reported that the more established, larger health organizations were the ones they tended to communicate with the most. The organizations with the highest levels of “Frequent” communication are listed in Table 1-9 below.

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Table 1-9: Organizations with the Highest Level of Frequent Contact with their Partners






5. Baltimore City Health Department - Office of Chronic Disease Prevention

14


7. Total Healthcare 12

8. Baltimore City Health Department - Baltimarket 11

9. Zeta Healthy Aging Partnership (Z-HAP) 10

10. Maryland Department of Health (DHMH) – CCDPC 10

11. Baltimore City Health Department - Office of Aging & Care Services 10

12. Baltimore City Health Department - Maternal & Child Health 9


14. Health Care Access Maryland 8


16. University of Maryland 8

17. B'more for Healthy Babies 8

18. MedStar Health and Hospital System 8

19. Amerigroup MCO 8


21. University of Maryland - School of Public Health 7

22. Baltimore City Health Department - Tobacco Use, CVD Prevention 7

23. University of Maryland Medical Center 7

24. Bmore Fit 7

25. Y of Central Maryland 7

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QUESTION 11: ORGANIZATIONS’ UNDERSTANDING OF PARTNER SKILL AND KNOWLEDGE

Question 11 asked survey respondents if they understood the skills and knowledge of each of the organizations they selected as partners. They were able to choose from a scale from highest to lowest, starting from “Strongly Agree, Agree, Disagree, or Strongly Disagree.” Overall, the largest group of respondents (53%) said they “strongly agree” that they understand the skills/knowledge of the organizations they deal with. In total, 95% of survey respondents agreed or strongly agreed that they understood the skills and knowledge of the contacts at the organizations they partner with. The responses, listed by percentage, are shown in Figure 1-14 below. Figure 1-14: Online Survey (Q11) - Organizations’ Understanding of Partner Skills/Knowledge

53%

42%

4%1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%

Strongly Agree Agree Disagree Strongly Disagree

I understand the skills and knowledge of my contacts at this organization

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QUESTION 12: HEALTHCARE ORGANIZATIONS: COMMUNICATION

Question 12 asked survey respondents what their primary means of communication was with their partners – whether via telephone, text message, e-mail, or in-person meetings. Each survey respondent was given an opportunity to answer the question specifically for each organization they deal with, the overall numbers showed a clear pattern. E-mail was the primary means of communication for most of the organizations, at 72%. In-person meetings were second, with 20%. Telephone contacts were 8% and text messages were less than one percent. One standout from the survey results is that the vast majority of communication between healthcare organizations in Baltimore City is via e-mail. In-person and telephone contact is relatively low (in comparison to other networks). The full results are listed in Figure 1-15 below. Figure 1-15: Online Survey (Q12) – Primary Means of Communication between Partners

IN-PERSON MEETINGS

Given that a fair amount of contact between healthcare partners in Baltimore City is done in-person (according to the organizations surveyed), the research team used the results to find out which organizations had the most in-person contact. According to survey respondents, the organizations listed in Table 1-10 below had the highest number of in-person meetings as their primary means of contact with that organization.

72%

20%

8%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

Email In-person Meetings Telephone Text Message

What is your primary means of communication with your contact at each organization?

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Table 1-10: Top 25 Organizations where In-Person Meetings are the Primary Means of Communication with Survey Respondents

Organization # of

Respondents

1. Zeta Healthy Aging Partnership (Z-HAP) 10



4. Y of Central Maryland 8

5. Baltimore City Health Department - Office of Chronic Disease Prevention 6

6. University of Maryland - School of Social Work 6


8. Total Healthcare 5

9. Morgan State University 5

10. Baltimore City Health Department - Tobacco Use, CVD Prevention 5

11. Waxter Center for Senior Citizens 5


13. B'more for Healthy Babies 4

14. Baltimore City Health Department - Baltimarket 4

15. Johns Hopkins - School of Nursing 4

16. Family League of Baltimore 4

17. Amerigroup MCO 4

18. Maryland Department of Education - School Health Services 4

19. Maryland Department of Health - Office of School Health 4

20. Latino Providers Network 4

21. American Heart Association - Cooking with Heart Kitchen 3

22. Coppin State University 3

23. Bmore Fit 3

24. Baltimore City Health Department - Maternal & Child Health 3


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WASHINGTON COUNTY: SOCIAL NETWORK ANALYSIS RESULTS

RESPONSE RATE

Ideally, network analysis will proceed from complete data. However, this is unusual to achieve in practice. The snowball sample identified 99 organizations, or divisions within organizations, and 104 recipients received the survey. Of that total, 59 responses were collected. Partial data on the non-respondents was obtained from those completed surveys.


Table 2-1 shows the 99 organizations in the network, categorized by CDC sector. Where conceptual overlap between sectors was encountered, organizations were categorized as follows:




Note: All network diagrams will use the colors below to represent their sector. Table 2-1: Network Organization Count by Sector

Sector Number of Organizations

Business 18

Government 11

Health System 35

Education 8

Community 12

Philanthropy 15

Total organizations/divisions in network 99

DENSITY

The 99 organizations reported a total of 381 connections. In a network this size, there are 9,702 possible connections. Thus, this network has a density of .039. In other words, 3.9% of all possible connections have been made. As figure 2 shows below, there is a web of fairly dense connections at the center of this network. However, a significant portion of the network is only weakly connected to the larger network. In particular, the number of nodes connected by only a single link may warrant attention.

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IN-DEGREE CENTRALITY

Two measures of degree centrality were obtained. In-degree centrality is the count of all nodes in a network reporting a link to a particular node. Table 3 presents the most central organizations by in-degree count. As shown in Table 2-2 below, the Washington County Health Department is the most central organization by in-degree centrality, with 17 other nodes (17% of the entire network) reporting connections to the Health Department. In-degree centrality drops quickly, with only 10 organizations showing 10 or more incoming connections. Table 2-2: In-degree Centrality, Washington County

Organization In-Degree Centrality

Washington County Health Department 17

Meritus Health 16

Meritus Medical Center 16

Maryland Department of Health 14

Western Maryland Health Systems 14

HEAL of Washington County 11

Washington County Public Schools 11

Washington County - Commission on Aging 10

Meritus Home Health Care 10

Walnut Street Community Health Center 10

Note: A full listing of all organization in this network, along with in-degree, out-degree, and betweenness centrality scores, may be found in Appendix D.

IN-DEGREE CENTRALITY: A VISUALIZATION

Figure 2-1 on the following page shows all 99 organizations collaborating in the network as well as all connections reported between these partners. In this figure, node size increases with in-degree centrality; as more organizations report working with a particular partner, that node increases in size in this figure. In other words, the largest nodes in this figure are those listed in Table 2-2 above.

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Figure 2-1: Washington County, Size by In-degree Centrality

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ORGANIZATIONS WITH OUTGOING CONNECTIONS

Organizations reporting the most connections going to other nodes in the network are shown below, in Table 2-3. The leading organizations report connections to nearly 1/3 of the entire network. However, the rate of outgoing connections quickly drops off. Only 14 organizations report 10 or more connections, with the majority of the network reporting zero outgoing connections. This suggests opportunities to further collaboration by developing reciprocal paths of communication throughout the network. It may also indicate that the leading organizations do not have sufficient capacity to do more than maintain existing outgoing connections, although further study is needed in order to make a determination. Table 2-3: Out-degree Centrality, Washington County

Organization Out-Degree Centrality

HEAL of Washington County 29

The Arc of Washington County 29

Washington County - Commission on Aging 28

Brothers United Who Dare to Care 28

Meritus Health - Parish Nursing 26

Washington County Health Department 25

Meritus Medical Center 22

University of MD Extension Office 20

Walnut Street Community Health Center 19

Meritus Medical Center - Behavioral & Community Health 19

Meritus Medical Center - Community Health, Education & Wellness

18

Western MD AHEC 15

Johns Hopkins University - Comstock Center 15

Way Station Behavioral Health 13


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Table 2-4: Organizations with Outgoing Connections, but No Reported Incoming Connections

Organization Outgoing Connections

Meritus Medical Center - Behavioral & Community Health 19

Meritus Medical Center - Community Health, Education & Wellness

18

Washington County Department of Social Services 9

Only three organizations that reported outgoing connections had no incoming connections. The table above lists those organizations. The relatively strong out-degree centrality of these community-related programs with zero reported in-coming connections may indicate a need to close the loop by encouraging community partners to communicate more effectively with these three organizations, particularly as the Meritus Medical Center divisions report connections to a significant portion of the network. The table above shows three organizations which reported significant out-going connections to other organizations. However, no organizations within the network reported working with these 3 nodes. This does not mean that other organizations do not work with these three nodes; it could mean that survey respondents are other organizations are not aware of partnerships with these organizations; it could also mean that these three nodes link with organizations that did not respond to the survey; or that partner organizations are not familiar with the work done by these three nodes. Regardless, this discrepancy does highlight the importance of making collaborative partnerships overt, and maintaining good working relationships with clear understanding of the role played by each organization in the network.


Betweenness centrality assesses how frequently a given node lies along the shortest path between any two other nodes in the network. Betweenness tends to identify nodes that serve as ‘bridges’ connecting clusters within a community. These bridges are particularly important, as they bring a network closer together and disseminate information to parts of a network that may be otherwise distant from one another. Betweenness, as calculated in Node XL, often follows a power law, so it tends to drop very quickly, and is a normal feature of networks. Put simply, networks seek to work through ‘hubs’ – nodes with high betweenness. An important consideration for network management is to identify which nodes serve as such hubs and to ensure that they have sufficient capacity to handle the load of information flowing through them. Table 2-6, on the following page, presents the organizations with the highest betweenness centrality in Washington County’s network.

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Table 2-5: Betweenness Centrality, Washington County


Centrality

Brothers United Who Dare to Care 1610.316

HEAL of Washington County 1384.887

Meritus Medical Center 1075.934

Washington County - Commission on Aging 1035.100

Washington County Health Department 916.616

The Arc of Washington County 805.329

Meritus Health - Parish Nursing 505.011

Walnut Street Community Health Center 464.454

DaVita Dialysis Center 375.867

University of MD Extension Office 282.761

Western MD AHEC 271.794

Johns Hopkins University - Comstock Center 221.033

Meritus Medical Center, Behavioral & Community health 192.706

Western Maryland Health Systems 166.939


BETWEENNESS CENTRALITY (BRIDGE ORGANIZATIONS VISUALIZATION)

Figure 2-2 shows the Washington County network, with nodes sized by betweenness centrality. For clarity, the figure shows a simplified depiction of the network, excluding outlying nodes. Note the strong bridging role played by community organizations.

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Figure 2-2: Washington County, Betweenness by Sector

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NETWORK GEOGRAPHICS

Figure 2-3 shows the geographical distribution of network organizations within Washington County. Each red dot in the figure marks the address of at least one network organization. Note that any organizations with an address outside of the county boundaries is not shown; also, that any organizations sharing the same address will only be marked by a single dot. However, a good sense of the distribution of network partners throughout this network can readily be made. Organizations are highly centralized around Hagerstown, the county seat and largest center of population in the county. However, distribution appears to match towns across the county. Because many of these towns have only one or two network organizations, strategic development of those partners to more efficiently and effectively serve their populations may result in gains in stability and service delivery across the network. Additionally, a strategic growth plan for the network may help continue the pattern of network distribution across the county.

____________________________________________________________________________________________________________________________________________________


Figure 2-3: Distribution of network organizations in Washington County

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WASHINGTON COUNTY: DISCUSSION & RECOMMENDATIONS

The Washington County Network is comprised of 99 partner organizations with 381 connections. There are a number of unusual features to the make-up of this network. One third of the network is made up of healthcare and health system organizations. Among these, Meritus plays a significant role. Eight divisions of Meritus were identified by survey respondents (nearly 10% of the entire network). Many of these divisions rank highly in one or more measures of centrality, indicating the extent to which they drive the network. With 18 organizations, private businesses comprise the second largest type of node. The number and diversity of businesses included in the network exceed those found in other networks and indicate a high level a high level of inter-sector collaboration. Table 2-6 lists these organizations, along with their centrality measures. Table 2-6: Private Business Organizations in the Washington County Network

Organization In-degree centrality

Out-degree

centrality

Betweenness centrality

Blossom School of Etiquette 0 0 0.000

Caldwell Manufacturing 4 2 2.354

Ellsworth Electric 0 0 0.000

Fahrney Keedy Home and Village 4 0 61.594

Fit in BoonsBoro 2 4 0.500

Hagerstown Volvo Group/Staywell Program 4 0 2.106

HBP, Inc. 1 1 0.000

Hub Labels 2 0 5.586

International Corporate Training and Marketing

0 0 0.000

Keller Stonebraker 2 4 18.657

Maugansville Garden Apartments 1 0 0.000

Meadow Kidney Care 2 7 63.684

Planet Fitness 1 0 0.000

Potomac Towers 3 0 0.461

Ruff Fitness 4 0 7.760

Staples Distribution 0 0 0.000

Steve Swayne Insurance 1 0 0.000

Walnut Towers 4 0 1.022

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Twenty-three reciprocal relationships among 17 organizations were reported. That is, in 23 instances, both partner organizations reported a mutual connection. While not a formal measure of centrality, reciprocal relationships can be useful in assessing the cohesiveness of a network by identifying collaborative ties with 2-way connections. These reciprocal linkages are shown in the figure below. Figure 2-4: Reciprocal Connections in Washington County

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LEVERAGING OPPORTUNITIES ARISING FROM THIS STUDY

Basic benefits from the fundamental act of mapping the network should not be overlooked. These include the following:

NETWORK EVALUATION

The size and composition of the network is now overt. In addition to recommendations made here, local health officials can undertake their own evaluation of how well suited the current partnerships are towards advancing the goals of chronic disease prevention. Strategic planning to incorporate new organizations into the network, or shift the capacity, centrality, or role of existing partners, may now be made.

PARTNER ORGANIZATIONS





________________________________________________________________________________________________________


Developing awareness of the network and acknowledging participation may be particularly important for smaller and community-oriented organizations on the periphery of the network. Many of these organizations are only weakly connected to the network, and may benefit not only from increased connections, but from increased recognition as well.

Several respondents from small organizations expressed sentiments of inferiority: A perception that ‘the real work’ is being done by larger, more central organizations; that the flow of communication is largely ‘outward’ from those large central organizations; and, that more recognition of the needs and accomplishments of small peripheral organizations is needed.



________________________________________________________________________________________________________


WASHINGTON COUNTY: SURVEY RESULTS AND KEY INFORMATION

WASHINGTON COUNTY SURVEY RESPONDENTS

The survey respondents represented a wide range of healthcare provider and awareness organizations in Washington County. Overall, 99 organizations in Washington County were contacted for the survey. Survey results show that a wide cross-section of organizations was represented. Examples of several key organizations include the following:

State and local government: Maryland Department of Health and Mental Hygiene (DHMH), Washington County Health Department

Major hospital/university systems: Meritus, University of Maryland Extension

Area universities: Frostburg State University

City government: Hagerstown Washington County Organization Types

Government health departments and government-affiliated organizations, along with community health organizations had a significant presence in the survey results.


Using the survey results, researchers were able to determine which organizations in Washington County had the highest number of in-degree and out-degree centrality. In other words, these organizations had the highest number of incoming and outbound connections to others in the network and most of them completed the survey. The range goes as follows: Nine out of the top 10 and 15 out of the top 25 in terms of network centrality completed the survey. They also provided important information about their relationships with other, less well-connected organizations, providing the research team with a stronger view into how the network operates.

________________________________________________________________________________________________________



Overall, the online survey was used to gather information about healthcare organizations in Washington County, find out who they partnered with, whether those organizations were in the County or elsewhere, and to collect quantitative and qualitative information about those relationships. The entire online survey can be viewed in Appendix B.

SECTION 1: WASHINGTON COUNTY HEALTH ORGANIZATIONS











Question 3 asked survey respondents to list their official job title. In Washington County, the vast majority of responses were completed by decision makers with job titles that referenced managerial or executive capacity. The most common job title was Director or Executive Director (41%). When including executives/founders, managers, and directors, a full 85% of decision makers at high levels completed the survey for Washington County. All survey respondents’ job titles are listed by percentage in Figure 2-5 on the following page.

________________________________________________________________________________________________________


Figure 2-5: Online Survey (Q3) – Survey Respondent Job Titles in Washington County




The next question asked survey respondents to state whether their organization was a Diabetes Program Partner (DPP) or not. In Washington County, no organization identified itself as such.


The last question in Section 1 asked respondents if their organization focused more on providing healthcare services or developing healthcare awareness. The Washington County results were a virtual tie, with 49% of survey respondents saying their focus was on healthcare provision or service delivery. The remaining 51% said they focused on developing awareness of chronic health issues. The answers about organization focus are represented in Figure 2-6 below.

Executive/Founder16%

Nurses/Nursing6%


41%

Manager28%

Coordinator3%

Community-based6%

Survey Respondent Job Titles - Washington County

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SECTION 2: WASHINGTON COUNTY HEALTH ORGANIZATIONS: RELATIONSHIPS

Section 2 presented survey respondents with a list of healthcare organizations in Washington County and asked them to select the ones they partnered with.


Question 7 asked survey respondents to view a list of healthcare organizations in Washington County and select the ones that they partnered with on various chronic health issues. This enabled the research team to compile of list of the most frequently selected healthcare organizations in the County, according to the survey respondents. Table 2-7 below lists the most frequently selected healthcare organizations in Washington County, ranked by the percentage of survey respondents who listed them as a partner. For example, the first entry on the list is the Washington County Health Department, with 60% – this means that a full 60% of the organizations surveyed said the Washington County Health Department was one of their partners.



Providing healthcare services for


0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


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Table 2-7: Top 20 Healthcare Organizations in Washington County (by % selected in the survey)


1. Washington County Health Department 60%

2. Meritus Medical Center 57%

3. Meritus Health 53%

4. Maryland Department of Health (DHMH) 50%

5. Western Maryland Health Systems 47%

6. Washington County Public Schools 37%

7. HEAL of Washington County 37%

8. Walnut Street Community Health Center 33%

9. Meritus Home Health Care 33%

10. Washington County - Commission on Aging 33%

11. Community Free Clinic 30%

12. Western MD Hospital 30%

13. Robinwood Family Practice 27%

14. Tri-State Community Health Center 27%

15. Maryland Department of Aging 27%

16. Meritus Health - Parish Nurse Organization 23%

17. City Of Hagerstown 23%

18. Hagerstown Heart 20%

19. Hospice of Washington County 20%

20. United Way 20%

The organizations listed above are very well-connected, so they are key organizations that serve the County, but there are several smaller organizations on the list that are well-connected despite their relatively smaller size. The Community Free Clinic and the Hospice of Washington County are two examples of small organizations who play a large role in the network. Aside from important government organizations like DHMH (at the state and county level), Meritus Health and its various divisions are a large part of the network structure.

SECTION 3: WASHINGTON COUNTY HEALTH ORGANIZATIONS: RELATIONSHIP QUALITY

Section 3 of the survey asked Washington County organizations about the type of relationships they had with the partner organizations they selected previously in Section 2. For every organization they selected, survey respondents were able to provide information about that partner with regard to upstream/downstream relationships, the length of their relationship, the frequency with which they communicated with partners, their understanding

________________________________________________________________________________________________________


of their partners’ skills and knowledge, and finally, their primary means of communication with partners.


After survey respondents selected the organizations they worked with, subsequent survey questions asked them to provide information about the nature of their relationship with those partners. The first question in Section 3 asked respondents to name which organizations gave them information (also known as an “upstream” relationship) and which organizations they sent information to (also known as a “downstream” relationship.) The list of the top organizations in terms of downstream partners is listed below in Table 2-8. According to survey respondents, the organizations on this list are distributing information or providing referrals to others (downstream) on a frequent basis. Table 2-8: Top 20 Organizations with the Highest Number of Downstream Partners


1. Washington County Health Department 11

2. Meritus Health 10


4. Meritus Medical Center 9

5. Western Maryland Health Systems 8

6. Maryland Department of Aging 6

7. Washington County - Commission on Aging 5

8. Western MD Hospital 5

9. HEAL of Washington County 4

10. Community Free Clinic 4

11. Cumberland YMCA 4

12. Meritus Home Health Care 4

13. Maryland Department Of Social Services 4

14. Brooklane Hospital 4

15. United Way 3

16. Tri-State Community Health Center 3

17. Robinwood Family Practice 3

18. VA Medical Center, Martinsburg WV 3

19. University of MD Extension Office 3

20. Washington County Public Schools 3

One of the standouts on the list is the Veterans Administration Medical Center in Martinsburg, West Virginia, located just across the border from Washington County. Again, quite a few of the organizations listed are smaller or community-based organizations.

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Question 9 asked survey respondents about the length of the relationships with the organizations they named as partners. A scale with 5 options was presented, with “Less than 1 year” to define the briefest relationship, and “More than 10 years” to define the longest-lasting relationships. In Washington County, survey respondents reported that the more established, larger health organizations were the ones they tended to have the longest relationships with. The organizations with the highest number of long-lasting relationships are listed in Table 2-9 below. Table 2-9: Organizations with the Highest Number of Partner Relationships Longer Than 10 Years

Organization # of Relationships











11. United Way 5



14. Walnut Street Community Health Center 4

15. Washington County Public Schools 4

16. Brooklane Hospital 4

17. City Of Hagerstown 3

18. Brothers United Who Dare to Care 3


20. Meritus Total Rehab Care - Wellness Center 3


Question 10 asked survey respondents how often they communicated with other organizations in their network. A scale with 4 options was presented, with “Frequently” to define the highest level of contact, followed by “Sometimes,” “Seldom,” or “Never” to describe less frequent levels of contact.

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Overall, survey respondents reported that the more established, larger health organizations were the ones they tended to communicate with the most. The organizations with the highest levels of “Frequent” communication are listed in Table 2-10 below. Table 2-10: Organizations with the Highest Level of Frequent Contact with their Partners










9. Meritus Health - Parish Nurse Organization 5





14. Meritus Weight Loss Center 4

15. City Of Hagerstown 3


Question 11 asked survey respondents if they understood the skills and knowledge of each of the organizations they selected as partners. They were able to choose from a scale from highest to lowest, starting from “Strongly Agree, Agree, Disagree, or Strongly Disagree.” Overall, the largest group of respondents (58%) said they “strongly agree” that they understand the skills/knowledge of the organizations they deal with. In total, 93% of survey respondents agreed or strongly agreed that they understood the skills and knowledge of the contacts at the organizations they partner with. The responses, listed by percentage, are shown in Figure 2-7 below.

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Question 12 asked survey respondents what their primary means of communication was with their partners – whether via telephone, text message, e-mail, or in-person meetings. Each survey respondent was given an opportunity to answer the question specifically for each organization they deal with, and the overall numbers showed a clear pattern. Like the other networks, e-mail was the primary means of communication for most of the organizations, at 52%. In-person meetings were second, with 30%. Telephone contacts were 17% and text messages were less than one percent. One standout from the survey results is that healthcare organizations in Washington County communicate with each other in-person at a high rate. The results are listed in Figure 2-8 below.

58%

35%

6%1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



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Figure 2-8: Online Survey (Q12) – Primary Means of Communication between Partners

IN-PERSON MEETINGS

Given that a good amount of contact between healthcare partners in Washington County is done in-person (according to the organizations surveyed), the research team used the results to find out which organizations had the highest number of in-person meetings. According to survey respondents, the organizations listed in Table 2-11 below had the highest number of in-person meetings as their primary means of contact with that organization.

52%

30%

17%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


What is your primary means of communication with your contact at each organization?

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Table 2-11: Organizations where In-Person Meetings are the Primary Means of Communication with Survey Respondents

Organization # of Respondents


2. Meritus Health 7




6. Meritus Health - Parish Nurse Organization 4


8. Walnut Street Community Health Center 3



11. Meritus Total Rehab Care - Wellness Center 3





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ALLEGANY/GARRETT COUNTIES: SOCIAL NETWORK ANALYSIS RESULTS

RESPONSE RATE

Ideally, network analysis will proceed from complete data. However, this is unusual to achieve in practice. The snowball sample identified 58 organizations, or divisions within organizations, and 65 recipients received the survey. Of that total, 41 responded. Partial data on the non-respondents was obtained from those completed surveys.


Table 2 shows the 58 organizations in the network, categorized by CDC sector. Where conceptual overlap between sectors was encountered, organizations were categorized as follows:





Sector Number of

Organizations

Business 3

Government 10

Health System 25

Education 11

Community 5

Philanthropy 4


DENSITY

The 58 organizations reported a total of 338 connections. In a network this size, there are 3,306 possible connections, leading to a network density of .098. While only approximately 10% of all possible connections have been made, Allegany/Garrett has the highest density of all networks in the study. The network is robust, as may be seen in Table 3-2, on the following page. Only a small minority of nodes are weakly connected (by one or two links).

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DEGREE CENTRALITY

Two measures of degree centrality were obtained. In-degree centrality is the count of all nodes in a network reporting a link to a particular node. Table 3-2, below, presents the most central organizations by in-degree count. As shown in the table, the Allegany County Health Department and the Western Maryland Health System are the most central organizations by this metric, with 15 other organizations reporting connections to each of these nodes. Table 3-2 lists all organizations with 10 or more connections. However, 40% of the network has an in-degree centrality of at least 7, meaning that nearly half of the network is reported to be in partnership with at least 12% of the whole network. Table 3-2: In-degree Centrality, Western Maryland


Allegany County Health Department 15

Western Maryland Health System 15

Garrett County Board of Education 12

Garrett County Health Department 12

Western Maryland Area Health Education Center 12

Maryland Physicians Care 11

Allegany County Public Schools 10

Tri-State Community Health Center 10

Western MD Health System - Center for Clinical Resources 10

Note: A full listing of all organization in this network, along with in-degree, out-degree, and betweenness centrality scores, may be found in Appendix E.

Figure 3-1 on the following page shows all 58 organizations collaborating in the network as well as all connections reported between these partners. In this figure, node size increases with in-degree centrality; as more organizations report working with a particular partner, that node increases in size in this figure. In other words, the largest nodes in this figure are those listed in the table above.

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Figure 3-1: Western MD, Size by In-degree Centrality

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Table 3-3 below presents the leading organizations by out-degree centrality – those organizations reporting the largest number of connections to the network. These top 13 organizations account for 83% of the connections in the network. Further assessment of out-degree centrality is limited by the survey completion rate. With only 50% response rate, it is to be expected that additional out-going connections were not captured due to non-response. Table 3-3: Out-degree Centrality, Western Maryland

Organization Out Degree Centrality

Western Maryland Health System 32

Associated Charities of Cumberland 30

Tri-State Community Health Center 29

Archway Station 26

Allegany County Health Department 25

Western Maryland Area Health Education Center 24

PharmaCare 24

Mid-Atlantic Healthcare 22

Western Maryland Regional Health Center, Outpatient Dialysis 22

Garrett County Health Department 19

Carver Community Center 14

Mountain Laurel Medical Center 13



Betweenness centrality assesses how frequently a given node lies along the shortest path between any two other nodes in the network. Betweenness tends to identify nodes that serve as ‘bridges’ connecting clusters within a community. These bridges are particularly important, as they bring a network closer together and disseminate information to parts of a network that may be otherwise distant from one another. Betweenness, as calculated in Node XL, often follows a power law, so it tends to drop very quickly, and is a normal feature of networks. Put simply, networks seek to work through ‘hubs’ – nodes with high betweenness. An important consideration for network management is to identify which nodes serve as such hubs and to ensure that they have sufficient capacity to handle the load of information flowing through them. Table 3-4 below presents the organizations with the highest betweenness centrality in Western Maryland’s network.

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Table 3-4: Betweenness Centrality, Western MD

Organization Betweenness Centrality

Garrett County Health Department 738.967

Western Maryland Health System 407.424

Western Maryland Area Health Education Center 346.746

Allegany County Health Department 282.746

Tri-State Community Health Center 250.353

Mid-Atlantic Healthcare 211.854

PharmaCare 199.295

Associated Charities of Cumberland 186.505

Archway Station 182.591

Western Maryland Regional Health Center, Outpatient Dialysis 89.877

Mountain Laurel Medical Center 84.539


BETWEENNESS CENTRALITY: A VISUALIZATION

Figure 3-2 shows the Western Maryland network, nodes sized by betweenness centrality. For clarity, the figure shows a simplified depiction of the network, excluding outlying nodes. Garrett and Allegany county health departments figure as prominent nodes, as do several health systems. The central community association (large light green node) is the Associated Charities of Cumberland.

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Figure 3-2: Western Maryland, Betweenness by Sector

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NETWORK GEOGRAPHICS

Figure 3-3 shows the geographical distribution of network organizations within Allegany and Garrett counties. Each red dot in the figure marks the address of at least one network organization. Note that any organizations with an address outside of the county boundaries is not shown; also, that any organizations sharing the same address will only be marked by a single dot. However, a good sense of the distribution of network partners throughout the two counties can readily be made. Distribution appears to be driven primarily by population. The majority of organizations are located in more populous Allegany County; the largest concentration of organizations occurs in and around Cumberland. Relatively few organizations are located in Garrett County, with a small cluster around Oakland, the county seat. Both counties are relatively sparsely populated. Although Allegany County is the larger of the two, nearly one-quarter of its population lives in Cumberland. For this network, effectively delivering services to a sparse and dispersed population is expected to pose ongoing challenges. Strategic management of network resources may be able to ensure efficient delivery. For this to happen, inter-governmental cooperation will be key, as will effective collaboration between public, nonprofit, and private sector partners.

____________________________________________________________________________________________________________________________________________________


Figure 3-3: Distribution of network organizations in Allegany and Garrett Counties

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DISCUSSION & RECOMMENDATIONS

The Western Maryland network includes organizations from Garrett and Allegany counties and is comprised of 338 connections between 58 organizations. Health systems are the largest sector – with 25 nodes – nearly half of the network consists of healthcare organizations. As may be seen in Figures 3-4 and 3-5 on the following pages, the preponderance of health systems organizations does not compromise the network. Figure 3-3 shows only the health systems organizations. As may be expected, there are robust connections between health systems. Note that only a single health system organization has only one connection to the larger health system network (see upper left quadrant of Figure 4). All other nodes show connections to at least three other health system nodes. However, figure 5 shows that when health systems are removed, no organizations are lost to the overall network. In other words, health systems do not dominate the lanes of communication – no organizations depend solely on a health systems organization for inclusion in the network. This suggests a robustness of connections throughout the network; that organizations connect to one another through a diverse range of sectors.

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WESTERN MD NETWORK (HEALTH SYSTEMS ONLY)

Figure 3-4: Western Maryland Network – (Health Systems Organizations Only)

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WESTERN MD NETWORK – WITHOUT HEALTH SYSTEMS ORGANIZATIONS

Figure 3-5 below shows a visualization of the network without Health Systems organizations. Figure 3-5: Western Maryland Network, Excluding Health Systems

This figure allows the central roles of the Garrett and Allegany County Health Departments to be clearly seen. Note also the bridging role between counties played by the University of Maryland Extension and Garrett County Board of Education.

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While Health Systems organizations are the largest bloc in the Allegany/Garrett Counties, community, nonprofit, and private businesses are each sparsely represented in the network. In particular, only three private organizations are active in the network – the Allegany Radio Corporation, Fechheimer Shirt Factory, and Uno Pizzeria and Grill. As a whole, the network exhibits a relatively high level of cohesiveness, with robust connections. In comparison, private businesses are only weakly connected; none report connections back to the network. Increasing connections with the private sector, and encouraging private enterprises to see themselves as active partners in chronic disease prevention, may be a means of significantly growing and strengthening this network.


Another measure of the cohesiveness of the network may be seen by isolating reciprocal links – those connections where both partners report working collaboratively. There are 39 such 2-way connections in Western Maryland involving 21 organizations. These reciprocal linkages are shown in Figure 3-6 below.

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Figure 3-6: Reciprocal Connections in Western Maryland

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LEVERAGE OPPORTUNITIES ARISING FROM THIS STUDY


NETWORK EVALUATION







________________________________________________________________________________________________________


Developing awareness of the network and acknowledging participation may be particularly important for smaller and community-oriented organizations on the periphery of the network. Many of these organizations are only weakly connected to the network, and may benefit not only from increased connections, but from increased recognition as well.

Several respondents from small organizations expressed sentiments of inferiority: A perception that ‘the real work’ is being done by larger, more central organizations; that the flow of communication is largely ‘outward’ from those large central organizations; and, that more recognition of the needs and accomplishments of small peripheral organizations is needed.



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ALLEGANY/GARRETT COUNTY: SURVEY RESULTS AND KEY INFORMATION

ALLEGANY/GARRETT COUNTY SURVEY RESPONDENTS

The survey respondents represented a wide range of healthcare provider and awareness organizations in the Counties. Overall, 58 organizations in Washington County were contacted for the survey. Survey results show that a wide variety of organizations were represented. Examples of several key organizations include the following:

State and local government: Maryland Department of Health and Mental Hygiene (DHMH), Allegany and Garrett County Health Departments

Major hospital/university systems: Western Maryland Health System, University of Maryland Extension

Community Organizations: YMCA, County United Way Allegany/Garrett County Organization Types Government and Health Systems organizations are numerous in the network, such as the Allegany and Garrett County Health Departments, and the Western Maryland Health System.


Using the survey results, researchers were able to determine which organizations in Western Maryland had the highest number of in-degree and out-degree centrality. In other words, these organizations had the highest number of incoming and outbound connections to others in the network and most of them completed the survey. The range goes as follows: 9 out of the top 10, and 22 out of the top 30 organizations all completed the survey. They also provided important information about their relationships with other, less well-connected organizations, providing the research team with a stronger view into how the Allegany/Garrett Network operates.

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Overall, the online survey was used to gather information about healthcare organizations in Allegany/Garrett County, find out who they partnered with, whether those organizations were in the County or elsewhere, and to collect quantitative and qualitative information about those relationships. The entire online survey can be viewed in Appendix B.

SECTION 1: ALLEGANY/GARRETT COUNTY HEALTH ORGANIZATIONS











Question 3 asked survey respondents to list their official job title. In Allegany/Garrett County, the vast majority of responses were completed by decision makers with job titles that referenced managerial or executive capacity. The most common job title was Director or Executive Director (38%). When including executives/founders, managers, and directors, 69% of decision makers at high levels completed the survey for Allegany/Garrett County. All survey respondents’ job titles are listed by percentage in Figure 3-7 on the following page.

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Figure 3-7: Online Survey (Q3) – Survey Respondent Job Titles in Allegany/Garrett Counties




The next question asked survey respondents to state whether their organization was a Diabetes Program Partner (DPP) or not. In Allegany/Garrett Counties, no organization identified itself as a DPP.


The last question in Section 1 asked respondents if their organization focused more on providing healthcare services or developing healthcare awareness. In total, 60% of survey respondents said their organization’s focus was on delivering healthcare services. The remaining 40% said they focused on developing awareness of chronic health issues. The answers about organization focus are represented in Figure 3-8 below.


Health/Nutrition12%


38%

Manager8%

Coordinator4%

Community-based15%


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SECTION 2: HEALTHCARE ORGANIZATIONS: RELATIONSHIPS

Section 2 presented survey respondents with a list of healthcare organizations in Allegany/Garrett County and asked them to select the ones they partnered with.


Question 7 asked survey respondents to view a list of healthcare organizations in Allegany/Garrett County and select the ones that they partnered with on various chronic health issues. This enabled the research team to compile of list of the most frequently selected healthcare organizations in the Counties, according to the survey respondents. Table 3-5 below lists the most frequently selected healthcare organizations in Allegany/Garrett County, ranked by the percentage of survey respondents who listed them as a partner. For example, the first entry on the list is the Allegany County Health Department, with 64% – this means that a full 64% of survey respondents said the Allegany County Health Department was one of their partners.





0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


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Table 3-5: Most-Connected Healthcare Organizations in Allegany/Garrett County (by % selected in the survey)


1. Allegany County Health Department 64%

2. Western Maryland Health System 60%

3. Garrett County Board of Education 52%

4. Western Maryland Area Health Education Center 52%

5. Garrett County Health Department 48%

6. Maryland Physicians Care 44%

7. Tri-State Community Health Center 40%

8. Western MD Health System - Center for Clinical Resources 40%

9. Allegany County Public Schools 40%

10. Pharmacare 36%

11. Western MD Health System - Parish Nursing Program 36%

12. Garrett County Memorial Hospital 36%

13. Western Maryland Medical Center 32%

14. Western MD Health System - Diabetes Clinic 32%

15. University of Maryland Extension 32%

16. Mountain Laurel Medical Center 28%

17. Priority Partners MCO 28%

18. Allegany County Human Resources Development Commission 28%

19. County United Way 28%

20. Children's Medical Group 28%

21. Allegany County Department of Social Services 28%

22. Allegany Health Nursing & Rehab 28%

23. Allegany County Health Department WIC (Women, Infants and Children)

28%

24. YMCA Cumberland 28%

25. Allegany Health Right 28%

The organizations listed above are very well-connected, so they are key organizations that serve the Counties, but there are several smaller organizations on the list that are well-connected despite their relatively smaller size. The Tri-State Community Health Center and the Children’s Medical Group are two examples. Another standout is that the Allegany and Garrett Health Departments, other government and education organizations including both counties’ Boards of Education, the Western Maryland Health System, and Western Maryland AHEC all account for 50% of the most well-connected organizations and are a large part of the network structure.

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SECTION 3: HEALTHCARE ORGANIZATIONS: RELATIONSHIP QUALITY

Section 3 of the survey asked Allegany/Garrett County organizations about the type of relationships they had with the partner organizations they previously selected in Section 2. For every organization they selected, survey respondents were able to provide information about that partner with regard to upstream/downstream relationships, the length of their relationship, the frequency with which they communicated with partners, their understanding of their partners’ skills and knowledge, and finally, their primary means of communication with partners.


After survey respondents selected the organizations they worked with, subsequent survey questions asked them to provide information about the nature of their relationship with those partners. The first question in Section 3 asked respondents to name which organizations gave them information (also known as an “upstream” relationship) and which organizations they sent information to (also known as a “downstream” relationship.) The list of the top organizations in terms of downstream partners is listed below in Table 3-6. According to survey respondents, the organizations on this list are distributing information or providing referrals to others (downstream) on a frequent basis.

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Table 3-6: Organizations with the Highest Number of Downstream Partners


1. Allegany County Health Department 11

2. Western Maryland Health System 11

3. Garrett County Board of Education 5

4. Western Maryland Area Health Education Center 8

5. Garrett County Health Department 7

6. Maryland Physicians Care 6

7. Allegany County Public Schools 5

8. Western MD Health System - Center for Clinical Resources 6


10. Western MD Health System - Parish Nursing Program 2

11. Pharmacare 3

12. Garrett County Memorial Hospital 7

13. Western MD Health System - Diabetes Clinic 4

14. University of Maryland Extension 4

15. Western Maryland Medical Center 4

16. Allegany Health Right 3

17. Allegany Health Nursing & Rehab 3

18. Allegany County Department of Social Services 4

19. Mountain Laurel Medical Center 4

20. Allegany County Human Resources Development Commission 4


Question 9 asked survey respondents about the length of the relationships with the organizations they named as partners. A scale with 5 options was presented, with “Less than 1 year” to define the briefest relationship, and “More than 10 years” to define the longest-lasting relationships. In Allegany/Garrett County, survey respondents reported that the more established, larger health organizations were the ones they tended to have the longest relationships with. The organizations with the highest number of long-lasting relationships are listed in Table 3-7 below.

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6



12. Allegany County Health Department - Cancer Prevention 5

13. Allegany County Health Department - Adult Eval. & Review Svcs. 5


15. Children's Medical Group 5

The trend of larger, government and large health systems organizations is prevalent in the results for this category.


Question 10 asked survey respondents how often they communicated with other organizations in their network. A scale with 4 options was presented, with “Frequently” to define the highest level of contact, followed by “Sometimes,” “Seldom,” or “Never” to describe less frequent levels of contact. Overall, survey respondents reported that the more established, larger health organizations were the ones they tended to communicate with the most. Those organizations, with the highest levels of “Frequent” communication, are listed in Table 3-8 below.

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Table 3-8: Top 20 Organizations with Highest Level of Frequent Contact with their Partners

Organization # Partners





5. Western Maryland Medical Center 7






11. Western MD Health System - Center for Clinical Resources 5

12. Maryland Physicians Care 4


14. Pharmacare 4

15. Children's Medical Group 4



3

18. Allegany Health Nursing & Rehab 3

19. Western MD Health System - Parish Nursing Program 3

20. Allegany County Health Department - Adult Eval. & Review Svcs. 3


Question 11 asked survey respondents if they understood the skills and knowledge of each of the organizations they selected as partners. They were able to choose from a scale from highest to lowest, starting from “Strongly Agree, Agree, Disagree, or Strongly Disagree.” Overall, the largest group of respondents (63%) said they “strongly agree” that they understand the skills/knowledge of the organizations they deal with. In total, 95% of survey respondents agreed or strongly agreed that they understood the skills and knowledge of the contacts at the organizations they partner with. The responses, listed by percentage, are shown in Chart 11 below.

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Question 12 asked survey respondents what their primary means of communication was with their partners – whether via telephone, text message, e-mail, or in-person meetings. Each survey respondent was given an opportunity to answer the question specifically for each organization they deal with, and the overall numbers showed a clear pattern. Like the other networks, e-mail was the primary means of communication for most of the organizations, at 52%. In-person meetings were second, with 30%. Telephone contacts were 17% and text messages were less than one percent. The full results are listed in Figure 3-10 below.

63%

32%

5%< 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



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IN-PERSON MEETINGS

Given that a relatively large amount of contact between healthcare partners in Allegany/Garrett County is done in-person (according to the organizations surveyed and when compared to other networks), the research team used the results to find out which organizations had the highest number of contacts who reported having in-person meetings with them. The organizations listed in Table 3-9 below had the highest number of survey respondents who said in-person meetings were their primary means of contact with that organization.

43%

34%

23%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%


What is your primary means of communication with the organizations you partner with?

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Organization # Respondents




4. County United Way 4

5. Allegany Radio Corporation 4






11. Housing Authority of the City of Cumberland 3

12. Garrett College 3

13. Allegany County Health Department - Cancer Prevention 3

14. Allegany County Chamber of Commerce 3



3

17. Western MD Health System - Diabetes Clinic 2

18. Alzheimer's Association 2


20. Allegany Health Education Center 2

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SOMERSET, WICOMICO, AND WORCESTER COUNTIES: SOCIAL NETWORK ANALYSIS

RESULTS

RESPONSE RATE

Ideally, network analysis will proceed from complete data. However, this is unusual to achieve in practice. The snowball sample identified 68 organizations, or divisions within organizations, and 79 representatives received the survey. Of that total, 46 responded to the survey. Partial data on the non-respondents was obtained from the completed surveys.

NETWORK DEMOGRAPHICS







Business 10

Government 24

Health System 12

Education 8

Community 7

Philanthropy 7

Total organizations/divisions in network

68

DENSITY

The 68 organizations reported a total of 257 connections. In a network this size, there are 4,556 possible connections, thus this network has a density of .055. This may mean that the network brings together organizations that may otherwise not work together. As may be seen in Figure 4-1 (pg. 107), this network has a number of weakly connected nodes. However, it does show evidence of significant bridging nodes as well as the development of

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lateral connections throughout the outer network. Both may warrant strategic management for optimal network growth and stability.

DEGREE CENTRALITY

Two measures of degree centrality were obtained. In-degree centrality is the count of all nodes in a network reporting a link to a particular node. Table 4-2 presents the most central organizations by in-degree count. As may be seen, by this metric, the Worcester County Health Department is the most central organization, with 14 other nodes (20% of the network) reporting a connection to the Health Department. The network is relatively small and does not exhibit a high level of in-degree centrality. However, the decline in centrality is relatively slow, with a quarter of the network reaching at least seven incoming connections from other nodes. Table 4-2: In-degree Centrality, Lower Shore


Worcester County Health Department 14

Wicomico County Health Department 12

Peninsula Regional Medical Center 12

Three Lower Counties - Main 9

Lower Shore Family YMCA 9


Maintaining Active Citizens (MAC) 8

Salisbury University 8

Atlantic General Hospital 8

Carefirst BlueCross BlueShield 8

Three Lower Counties - Community Services 8

McCready Foundation 8

WBOC-TV 16 7

WMDT-TV 47 7

Somerset County Health Department 7

Note: A full listing of all organization in this network, along with in-degree, out-degree, and betweenness centrality scores, may be found in Appendix F.

IN-DEGREE CENTRALITY

Figure 4-1 below shows all 68 organizations collaborating in the network as well as all connections reported between these partners. In this figure, node size increases with in-degree

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centrality; as more organizations report working with a particular partner, that node increases in size in this figure. In other words, the largest nodes in this figure are those listed in Table 4-2. Figure 4-1: Lower Shore, Size by In-degree Centrality

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Table 4-3 below shows the level of out-degree centrality, or number of connections from each node to other partner organizations. As the table shows, the number of outgoing connections drops quickly, although this may be due in part to the survey response rate. With only 50% of the network responding, it may be expected that additional outgoing connections exist but were not reported. The connections shown in Table 4-3 account for 2/3 of all reported network connections, giving a sense of the impact that these organizations have as drivers of the network and its partnerships. Table 4-3: Out-degree centrality, Lower Shore


Maintaining Active Citizens (MAC) 33

Worcester County Health Department 32

Wicomico County Health Department 30

Worcester County Board of Education 25

Richard A. Henson YMCA 13

Somerset County Health Department, Behavioral Health 12

YMCA of the Chesapeake 11

Health and Outreach Point of Entry (HOPE) 10

Worcester County Public Schools 10



Betweenness centrality assesses how frequently a given node lies along the shortest path between any two other nodes in the network. Betweenness tends to identify nodes that serve as ‘bridges’ connecting clusters within a community. These bridges are particularly important, as they bring a network closer together and disseminate information to parts of a network that may be otherwise distant from one another. Betweenness, as calculated in Node XL, often follows a power law, so it tends to drop very quickly, and is a normal feature of networks. Put simply, networks seek to work through ‘hubs’ – nodes with high betweenness. An important consideration for network management is to identify which nodes serve as such hubs and to ensure that they have sufficient capacity to handle the load of information flowing through them.

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Table 4-4 presents the organizations with the highest betweenness centrality in the Lower Shore network. Table 4-4: Betweenness Centrality, Lower Shore


Worcester County Health Department 1711.331

Maintaining Active Citizens (MAC) 1132.430

Wicomico County Health Department 716.179

Worcester County Board of Education 445.454

Richard A. Henson YMCA 310.380

Somerset Wellness Center 163.223

Lower Shore Family YMCA 116.522

Peninsula Regional Medical Center 101.553

Three Lower Counties Community Services 70.716

American Heart Association 69.785

Carefirst BlueCross BlueShield 66.293


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Figure 4-2 shows the network with nodes sized by betweenness centrality. For clarity, the figure shows a simplified depiction of the network, excluding outlying nodes. Figure 4-2: Lower Shore, Betweenness by Sector

Wicomico and Worcester County Health Departments are the most central government agencies in this figure. The large orange node represents the Worcester County Board of Education, while the two largest community nodes (light green) are the Richard A. Henson YMCA and Maintaining Active Citizens (MAC).

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NETWORK GEOGRAPHICS

Figure 4-3 shows the geographical distribution of network organizations within Somerset, Wicomico, and Worcester counties. Each red dot in the figure marks the address of at least one network organization. Note that any organizations with an address outside of the counties’ boundaries are not shown; also, any organizations sharing the same address will only be marked by a single dot. However, a good sense of the distribution of network partners throughout the three counties can readily be made. Somerset County is only lightly represented by network organizations as may be seen on the map. A particular concern will be to ensure that residents of this county are adequately served by partner organizations located in either Wicomico or Worcester counties. Worcester County, with roughly twice the population as Somerset, is home to significantly more network organizations, most located along the Route 113 corridor. While this means that organizations are relatively well dispersed throughout the county, particularly across major roads and population centers, Wicomico shows a cluster of networks in and around Salisbury. While Salisbury is home to one-third of the county’s residents, adequate coverage should be given to the remaining population. Strategic development of this network should include careful consideration of how to effectively grow the network so as to increase coverage to a dispersed citizenry in these relatively sparsely populated counties. In order to deliver services effectively across this area, close intergovernmental cooperation will be required. Additionally, nonprofit organizations should be utilized as effectively as possible and relationships with key private businesses grown.

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Figure 4-3: Distribution of Network Organizations, Lower Shore

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LOWER SHORE: DISCUSSION & RECOMMENDATIONS

The Lower Shore network covers Somerset, Wicomico, and Worcester counties and is made up of 257 connections between 68 partner organizations. Government agencies are the largest bloc within the network, making up one-third of the network and encompassing a wide array of organizations. In particular, this network has greater participation of Parks and Recreation, and Fire Departments than do other networks. This broad outreach through a variety of government services is a strength for this network. Figure 4-4 below shows the connections between government agencies in this network. As the figure shows, county health departments play a critical role in maintaining connections among government agencies. Figure 4-4: Government Agencies in the Lower Shore network

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The private sector is well-represented, compared to other local health networks in the study. However, the majority of private businesses are only weakly connected to the network, and there does not appear to be a pattern to those connections. Development of a coordinated strategic plan among all three counties to more effectively incorporate private sector organizations may be a means of strengthening this network and more effectively delivering services and information to citizens.


A sense of the cohesiveness of the network may be gained by isolating reciprocal connections. These are linkages where two partners each report working together. In other words, these are the two-way connections. Figure 4-5 presents all reciprocal links reported in the Lower Shore network. Figure 4-5: Reciprocal Linkages in the Lower Shore Network

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This figure highlights the central role played by county health departments in this network, as well as of the strong bridging role of the Three Lower Counties Community Services. Also of note are the broad representation of organizations from different sectors, an indicator of strong cross-sector collaboration. Twenty-three reciprocal relationships among 17 organizations were reported. One quarter of the network partners, representing 18 percent of all connections, were reciprocal.



NETWORK EVALUATION






________________________________________________________________________________________________________



Developing awareness of the network and acknowledging participation may be particularly important for smaller and community-oriented organizations on the periphery of the network. Many of these organizations are only weakly connected to the network, and may benefit not only from increased connections, but from increased recognition as well. Several respondents from small organizations expressed sentiments of inferiority: A perception that ‘the real work’ is being done by larger, more central organizations; that the flow of communication is largely ‘outward’ from those large central organizations; and, that more recognition of the needs and accomplishments of small peripheral organizations is needed.


The previous point addressed relations between central and peripheral organizations. Relationships among peripheral organizations, particularly those sharing a set of common characteristics (size, audience, mission, etc.) have different needs and require a different management strategy. Capturing those organizations and their needs can be difficult. Some local organizations reported not being aware of organizational or contact names in the network. Convincing small organizations that their partnership is a valued contribution to the network can be challenging. Limited response rates from small organizations may be one indicator of this. That response rate limited analysis of the periphery and showed a higher level of uni-directional connections from the center to the periphery than may be the case in actuality. Put simply, it is to be expected that peripheral organizations have more ties than are shown. This is supported by discussion with some respondents from small peripheral organizations who report a strong sense of collaborative partnership with other such organizations. These relationships were described as frequent, consisting of collaborative back-and-forth, and multi-modal (e-mail bolstered with calls and in-person meetings). Additionally, these collaborations were attributed in part to a lack of resources and a resultant need to work together for mutual success. To the extent possible, these collaborative partnerships should be acknowledged and encouraged.

________________________________________________________________________________________________________


SOMERSET, WICOMICO, AND WORCESTER COUNTIES: SURVEY RESULTS AND KEY

INFORMATION

SURVEY RESPONDENTS

The survey respondents represented a wide range of healthcare provider and awareness organizations in the Counties. Overall, 67 organizations in the Counties were contacted for the survey. Survey results show that a wide variety of organizations were represented. Examples of several key organizations include the following:

State and local government: Somerset, Wicomico, and Worcester Health Departments

Major hospital/university systems: Peninsula Regional Medical Center

Community Organizations: Maintaining Active Citizens (MAC), Lower Shore YMCA Somerset, Wicomico, and Worcester County Organization Types The Counties have a very diverse group of organizations, including city and town governments, schools, and media organizations.


Using the survey results, researchers were able to determine which organizations in the Counties had the highest number of in-degree and out-degree centrality. In other words, these organizations had the highest number of incoming and outbound connections to others in the network and most of them completed the survey. The range goes as follows: 9 out of the top 10 and 16 out of the top 25 most central organizations all completed the survey. They also provided important information about their relationships with other, less well-connected organizations, providing the research team with a stronger view into how the Lower Shore Network operates.

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Overall, the online survey was used to gather information about healthcare organizations in Lower Shore Counties, find out who they partnered with, whether those organizations were in the Counties or elsewhere, and to collect quantitative and qualitative information about those relationships. The entire online survey can be viewed in Appendix B.

SECTION 1: SOMERSET/WICOMICO/WORCESTER COUNTIES HEALTH ORGANIZATIONS











Question 3 asked survey respondents to list their official job title. In Somerset/Wicomico/Worcester Counties, the vast majority of responses were completed by decision makers with job titles that referenced managerial or executive capacity. The most common job title was Director or Executive Director (61%). When including executives/founders, managers, and directors, 75% of decision makers at high levels completed the survey. All survey respondents’ job titles are listed by percentage in Figure 4-6 on the following page.

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Figure 4-6: Online Survey (Q3) – Survey Respondent Job Titles, Lower Shore




The next question asked survey respondents to state whether their organization was a Diabetes Program Partner (DPP) or not. In Somerset/Wicomico/Worcester Counties, no organization identified itself as a DPP.

Executive/Founder7%

Health/Nutrition11%


61%

Manager7%

Coordinator7%

Community-based7%


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The last question in Section 1 asked respondents if their organization focused more on providing healthcare services or developing healthcare awareness. In total, 56% of survey respondents said their organization’s focus was on delivering healthcare services. The remaining 44% said they focused on developing awareness of chronic health issues. The answers about organization focus are in Figure 4-7 below. Figure 4-7: Online Survey (Q6) – Organization Focus: Healthcare Awareness or Service Delivery


Section 2 presented survey respondents with a list of healthcare organizations in the Counties and asked them to select the ones they partnered with.


Question 7 asked survey respondents to view a list of healthcare organizations in the Counties and select the ones that they partnered with on various chronic health issues. This enabled the research team to compile of list of the most frequently selected healthcare organizations in the Counties, according to the survey respondents.





0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


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Table 4-5 below lists the most-frequently selected healthcare organizations in the Counties, ranked by the percentage of survey respondents who listed them as a partner. For example, the first entry on the list is the Peninsula Regional Medical Center, with 50% – this means that a full 50% of the organizations surveyed said the Center was one of their partners. Table 4-5: Most-Connected Healthcare Organizations, Lower Shore (by % selected in the survey)


1. Peninsula Regional Medical Center 50%

2. Wicomico County Health Department 46%

3. Three Lower Counties - Main 39%

4. Worcester County Health Department 39%

5. Maintaining Active Citizens (MAC) 36%

6. Somerset County Health Department 32%


8. Three Lower Counties - Community Services 32%

9. Lower Shore Family YMCA 32%

10. Carefirst BlueCross BlueShield 32%

11. WBOC-TV 16 29%

12. McCready Foundation 29%

13. Salisbury University 29%

14. Atlantic General Hospital 29%

15. WMDT-TV 47 25%

16. Somerset Wellness 21%

17. Wicomico County Government 21%

18. Richard A. Henson Family YMCA 21%

19. Crisfield Clinic 21%

20. Wicomico County Board Of Education 18%

The top 20 organizations listed above are very well-connected, so they are key organizations that serve the Counties, but there are several smaller organizations on the list that are well-connected despite their relatively smaller size. Maintaining Active Citizens (MAC) and Somerset Wellness are two examples.

IMPORTANCE OF NON-TRADITIONAL ORGANIZATIONS

Other standouts are the presence of non-traditional organizations such as WBOC, WMDT, and the Daily Times. In addition, there are four different Departments of Parks and Recreation that play an important role in this network (Somerset, Wicomico, Worcester, and Snow Hill). There is also a strong multi-location YMCA presence, and other non-traditional organizations present such as Taylor Bank, Pizzeria Uno, and the Casino at Ocean Downs.

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Section 3 of the survey asked Lower Shore organizations about the type of relationships they had with the partner organizations they selected previously in Section 2. For every organization they selected, survey respondents were able to provide information about that partner with regard to upstream/downstream relationships, the length of their relationship, the frequency with which they communicated with partners, their understanding of their partners’ skills and knowledge, and finally, their primary means of communication with partners.


After survey respondents selected the organizations they worked with, subsequent survey questions asked them to provide information about the nature of their relationship with those partners. The first question in Section 3 asked respondents to name which organizations gave them information (also known as an “upstream” relationship) and which organizations they sent information to (also known as a “downstream” relationship.) The list of the top organizations in terms of downstream partners is listed below in Table 4-6. According to survey respondents, the organizations on this list are distributing information or providing referrals to others (downstream) on a frequent basis. Table 4-6: Organizations with the Highest Number of Downstream Partners


1. Peninsula Regional Medical Center 9

2. Carefirst BlueCross BlueShield 8

3. Three Lower Counties - Main 8

4. Three Lower Counties - Community Services 6

5. Salisbury University 5

6. McCready Foundation 5

7. Atlantic General Hospital 5

8. Worcester County Health Department 5

9. Maintaining Active Citizens (MAC) 5

10. Crisfield Clinic 5

11. Lower Shore Family YMCA 4

12. Somerset County Health Department 4

13. Wicomico County Health Department 4

14. Worcester County - Local Management Board 4

15. Worcester County Parks and Recreation 3


17. Somerset County Department of Parks & Recreation 3

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Question 9 asked survey respondents about the length of the relationships with the organizations they named as partners. A scale with 5 options was presented, with “Less than 1 year” to define the briefest relationship, and “More than 10 years” to define the longest-lasting relationships. In the Counties, survey respondents reported that the more established, larger health organizations were the ones they tended to have the longest relationships with. The organizations with the highest number of long-lasting relationships are listed in Table 4-7 below. Table 4-7: Organizations with the Highest Number of Partner Relationships Longer Than 10 Years





4. Wicomico County Government 5


6. WMDT-TV 47 5


8. McCready Foundation 5

9. WBOC-TV 16 4

10. Pocomoke High School 4

11. Worcester County Parks and Recreation 3

12. Pocomoke Elementary School 3

13. Wicomico County Public Schools 3

14. Pocomoke Middle School 3

15. The Daily Times 3






While many of the long-term relationships here are with the larger government and health systems organizations, there are quite several non-traditional organizations with a long record of relationships, including the two television stations, two school systems, and the Daily Times.

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Question 10 asked survey respondents how often they communicated with other organizations in their network. A scale with 4 options was presented, with “Frequently” to define the highest level of contact, followed by “Sometimes,” “Seldom,” or “Never” to describe less frequent levels of contact. Overall, survey respondents reported that the more established, larger health departments, medical centers/hospitals and large community organizations were the ones they tended to communicate with the most. Those organizations, with the highest levels of “Frequent” communication, are listed in Table 4-8 below. Table 4-8: Top 20 Organizations with Highest Level of Frequent Contact with their Partners















14. Somerset Wellness 3

15. Wicomico County Board Of Education 3



18. Town of Berlin 3

19. Snow Hill Volunteer Fire Department 2

20. Wicomico County Department of Recreation, Parks, and Tourism

2

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Question 11 asked survey respondents if they understood the skills and knowledge of each of the organizations they selected as partners. They were able to choose from a scale from highest to lowest, starting from “Strongly Agree, Agree, Disagree, or Strongly Disagree.” Overall, the largest group of respondents (63%) said they “strongly agree” that they understand the skills/knowledge of the organizations they deal with. In total, 95% of survey respondents agreed or strongly agreed that they understood the skills and knowledge of the contacts at the organizations they partner with. The responses, listed by percentage, are shown in Figure 4-8 below. Figure 4-8: Online Survey (Q11) - Organizations’ Understanding of Partner Skills/Knowledge


Question 12 asked survey respondents what their primary means of communication was with their partners – whether via telephone, text message, e-mail, or in-person meetings. Each survey respondent was given an opportunity to answer the question specifically for each organization they deal with, and the overall numbers showed a clear pattern. Like the other networks, e-mail was the primary means of communication for most of the organizations, at 49%. In-person meetings were second, with 36%. Telephone contacts were 15% and text messages were zero. The full results are listed in Figure 4-9 below.

63%

32%

5%< 1%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



________________________________________________________________________________________________________



IN-PERSON MEETINGS

Given that a fair amount of contact between healthcare partners in the Counties is done in-person (according to the organizations surveyed), the research team used the results to find out which organizations had the highest number of contacts who reported having in-person meetings with them. The organizations listed in Table 4-9 below had the highest number of survey respondents who said in-person meetings were their primary means of contact with that organization.

49%

36%

15%

0%0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



________________________________________________________________________________________________________


Table 4-9: Top 20 Organizations where In-Person Meetings are the Primary Means of Communication with Survey Respondents

Organizations # of Respondents



3. Richard A. Henson Family YMCA 4







10. Public Access Channel PAC-14 3

11. Deer's Head Center 3

12. Wicomico YMCA 3

13. Worcester County - Local Management Board 2

14. Worcester County Board of Education 2

15. Wicomico County Public Schools 2

16. Somerset Wellness 2


18. St. Paul's United Methodist Church 2

19. Wicomico County Board Of Education 2


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CAROLINE AND DORCHESTER COUNTIES: SOCIAL NETWORK ANALYSIS RESULTS

RESPONSE RATE

Ideally, network analysis will proceed from complete data. However, this is unusual to achieve in practice. The snowball sample identified 81 organizations, or divisions within organizations, and 83 survey recipients. Of that total, 52 responded to the survey. Partial data on the non-respondents was obtained from the completed surveys.

HEALTHCARE ORGANIZATIONS BY SECTOR




Nonprofit organizations not operating as a health system were categorized as philanthropies



Business 3

Government 16

Health System 17

Education 10

Community 9

Philanthropy 26


DENSITY

The 81 organizations reported a total of 570 connections. In a network this size, there are 6,480 possible connections. Thus, this network has a density of .086. In other words, nearly 9% of all possible connections have been made. As may be seen in Figure 5-1, below, this has resulted in a densely connected inner core with a significant portion of the network only weakly connected to that center. This may indicate that this network is successful at bringing in organizations that otherwise have no connection to each

________________________________________________________________________________________________________


other. Strategic management of this network may increase lateral connections among these nodes.

DEGREE CENTRALITY

Two measures of degree centrality were obtained. In-degree centrality is the count of all nodes in a network reporting a link to a particular node. Table 5-2 presents the most central organizations by in-degree count. As may be seen, Associated Black Charities is, by this metric, the most central node, with 20 (25% of the network) reporting connections to this organization. Centrality declines moderately: 25% of the network has an in-degree centrality of at least 11 connections, while 2/3 of the network has five or more incoming connections. Table 5-2: In-degree Centrality, Caroline & Dorchester Counties


Associated Black Charities 20

Caroline County Health Department 18

Shore Health Systems 18

DHMH - Healthiest Maryland Businesses - Lower Eastern Shore

16

Dorchester Co. Health Department Health Enterprise Zone 16

Choptank Community Health Systems 16

Dorchester County Health Department 15



Eastern Shore Area Health Education Center 12

Centers for Disease Control 12

Union Bethel AME Church 12

YMCA of the Chesapeake 12

Judy Center 12

Caroline County Health Department - Women, Infants, and Children (WIC)

11

Dorchester County Department of Social Services 11

Dorchester County Wellness Coalition 11

Dri-Dock Recovery and Wellness Center 11

Note: A full listing of all organization in this network, along with in-degree, out-degree, and betweenness centrality scores, may be found in Appendix G.

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Figure 5-1 below shows all 81 organizations collaborating in the network as well as all connections reported between these partners. In this figure, node size increases with in-degree centrality; as more organizations report working with a particular partner, that node increases in size in this figure. In other words, the largest nodes in this figure are those listed in table 3. Figure 5-1: Caroline & Dorchester Counties, size by in-degree centrality

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Table 5-3: Out-degree centrality, Caroline & Dorchester Counties


Maryland Health Connection - Dorchester Navigator 59

Dorchester County Health Department - Health Education 58

Dorchester County Health Department 50

Associated Black Charities 45

University of Maryland - Shore Regional Health 43

Eastern Shore Area Health Education Center 37

Choptank Community Health Systems 34

Dorchester County Health Department - Community Outreach 34

University of Maryland Eastern Shore - School of Pharmacy - Evaluation

21

Dorchester County YMCA 19


Table 5-3, above, presents the leading organizations by out-degree centrality – those organizations reporting the largest number of connections to the network. These top 10 organizations account for 70% of the connections in the network. Further assessment of out-degree centrality is limited by the survey completion rate. With only a 50% response rate, it is to be expected that additional out-going connections were not captured due to non-response.


Betweenness centrality assesses how frequently a given node lies along the shortest path between any two other nodes in the network. Betweenness tends to identify nodes that serve as ‘bridges’ connecting clusters within a community. These bridges are particularly important, as they bring a network closer together and disseminate information to parts of a network that may be otherwise distant from one another. Betweenness, as calculated in Node XL, often follows a power law, so it tends to drop very quickly, and is a normal feature of networks. Put simply, networks seek to work through ‘hubs’ – nodes with high betweenness. An important consideration for network management is to identify which nodes serve as such hubs and to ensure that they have sufficient capacity to handle the load of information flowing through them.

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Table 5-4 presents the organizations with the highest betweenness centrality in the Caroline & Dorchester Counties network. Table 5-4: Betweenness Centrality, Caroline & Dorchester Counties


Centrality

Maryland Health Connection - Dorchester Navigator 979.414

Dorchester County Health Department - Health Education 966.513

Dorchester County Health Department 828.210

Associated Black Charities 493.092

University of Maryland - Shore Regional Health 420.130

Caroline County Health Department 311.947

Choptank Community Health Systems 311.345

Eastern Shore Area Health Education Center 303.653

Dorchester County Health Department - Community Outreach 233.808

Union Bethel AME Church 126.351

DHMH - Healthiest Maryland Businesses - Lower Eastern Shore 102.615


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Figure 5-2 shows the Caroline & Dorchester counties network, nodes sized by betweenness centrality. For clarity, the figure shows a simplified depiction of the network, excluding outlying nodes. Figure 5-2: Caroline & Dorchester Counties, Betweenness by Sector

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The five largest government agencies (blue nodes) include the Maryland Health Exchange, Caroline and Dorchester County Health Departments as well as the Community Outreach and Health Education divisions of the Dorchester County Health Department. Choptank Community Health System features prominently as do the University of Maryland’s Shore Regional Health and the Eastern Shore Area Health Education Center. The Associated Black Charities is the most central nonprofit organization in this network.

NETWORK GEOGRAPHICS

Figure 5-3 shows the geographical distribution of network organizations within this network. Each red dot in the figure marks the address of at least one network organization. Note that any organizations with an address outside of the city limits is not shown; also, that any organizations sharing the same address will only be marked by a single dot. However, a good sense of the distribution of network partners throughout the city can readily be made. Distribution of network organizations is driven by population. Nearly the entirety of this network is located in the county seats, with only three organizations based outside of these two communities. The county seats are the most populous towns in each county. Cambridge, in Dorchester County, accounts for just over one-third of the county population. However, a significant portion of each county lives outside these two communities. A central challenge for this highly centralized geographically located network will be to ensure that the rural population is adequately served. Intergovernmental coordination will be needed to make effective use of resources. In addition, nonprofit partners will play a key role in serving citizens.

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Figure 5-3: Distribution of network organizations in Caroline and Dorchester Counties

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DISCUSSION & RECOMMENDATIONS

The chronic disease local health network in Caroline and Dorchester counties is comprised of 81 distinct organizations or divisions of organizations, connected through 570 linkages. Community and nonprofit organizations are the largest sectors, accounting for 45% of the organizations in the network. While these sectors dominate the network numerically, that dominance does not compromise the network. As may be seen in Figure 5-4 on the following page, removing the nonprofit and community organizations does not result in the loss of any other organizations from the network. In fact, Figure 5-4 shows a robust set of connections between organizations in other sectors; none are isolated and all are connected to at least two other organizations.

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Figure 5-4: Caroline & Dorchester Counties, Excluding Nonprofit & Community Organizations

Government, Health System, and Education sector organizations are also well-represented. The business sector is the least well-represented sector, with only three private organizations involved in the network. One avenue of growth for this network is to develop strategies for including a wider variety of private businesses into the network. In particular, some networks

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have developed effective partnerships with local employers and industries; a tactic that may work well here. However, taken as a whole, the network shows robust connections throughout as well as good cross-sector collaboration. This network is the second densest network in the study, closely following Western Maryland.


Another perspective on the network may be gained by looking only at the reciprocal linkages – those connections where both partners report a mutual connection. Forty-one reciprocal links were reported, involving 21 organizations. All together, this accounts for one-quarter of the organizations in the network, and only 14% of all reported connections. Encouraging more mutual connections may be an effective way to increase the effectiveness and the stability of the network. One possible explanation for the low level of reciprocal connections reported in this network may be a lack of awareness of network partners. Thus, publicizing the network to all partner organizations, and educating organizations on the mission of partner organizations may be an easy way to increase collaboration. Figure 5-2 (pg. 133), showed the network by betweenness centrality – increasing the size of those nodes who tended to act as ‘bridges’ by existing along the shortest path between other nodes.


Graphic depictions of networks can provide much useful information, but also have limitations. In this case, examining the betweenness scores reveals the state of the network more clearly. As may be seen in Table 5-5, the first three organizations have very high betweenness scores – but they drop significantly, from the high 900’s down to 828, then a dramatic drop to 493. Table 5-5: Betweenness Centrality Scores for Caroline & Dorchester Counties


1. Maryland Health Connection - Dorchester Navigator 979.414

2. Dorchester County Health Department - Health Education 966.513

3. Dorchester County Health Department 828.210

4. Associated Black Charities 493.092

5. University of Maryland - Shore Regional Health 420.130

6. Caroline County Health Department 311.947

7. Choptank Community Health Systems 311.345

8. Eastern Shore Area Health Education Center 303.653

________________________________________________________________________________________________________


This more clearly allows the central role of government agencies, particularly those located in Dorchester County, to be seen. The Dorchester County Health Department (#2 and 3) plays a critical role in maintaining information flow throughout the network. Bringing Caroline County into a more central role may improve network effectiveness. Similarly, effective management and communication with Associated Black Charities is recommended in order to maintain collaborative partnerships with that organization’s bridge partners.



NETWORK EVALUATION






________________________________________________________________________________________________________



Developing awareness of the network and acknowledging participation may be particularly important for smaller and community-oriented organizations on the periphery of the network. Many of these organizations are only weakly connected to the network, and may benefit not only from increased connections, but from increased recognition as well. Several respondents from small organizations expressed sentiments of inferiority: A perception that ‘the real work’ is being done by larger, more central organizations; that the flow of communication is largely ‘outward’ from those large central organizations; and, that more recognition of the needs and accomplishments of small peripheral organizations is needed.


The previous point addressed relations between central and peripheral organizations. Relationships among peripheral organizations, particularly those sharing a set of common characteristics (size, audience, mission, etc.) have different needs and require a different management strategy. Capturing those organizations and their needs can be difficult. Some local organizations reported not being aware of organizational or contact names in the network. Convincing small organizations that their partnership is a valued contribution to the network can be challenging. Limited response rates from small organizations may be one indicator of this. That response rate limited analysis of the periphery and showed a higher level of uni-directional connections from the center to the periphery than may be the case in actuality. Put simply, it is to be expected that peripheral organizations have more ties than are shown. This is supported by discussion with some respondents from small peripheral organizations who report a strong sense of collaborative partnership with other such organizations. These relationships were described as frequent, consisting of collaborative back-and-forth, and multi-modal (e-mail bolstered with calls and in-person meetings). Additionally, these collaborations were attributed in part to a lack of resources and a resultant need to work together for mutual success. To the extent possible, these collaborative partnerships should be acknowledged and encouraged.

________________________________________________________________________________________________________


CAROLINE AND DORCHESTER COUNTIES: SURVEY RESULTS AND KEY INFORMATION

SURVEY RESPONDENTS

The survey respondents represented a wide range of healthcare provider and awareness organizations in the Counties. Overall, 81 organizations in the Counties were contacted for the survey. Survey results show that a wide variety of organizations were represented. Examples of several key organizations include the following:

State and local government: Caroline and Dorchester Health Departments

Health systems: Choptank Community Health Systems, Eastern Shore Area Health Center

Community Organizations: Associated Black Charities, YMCA of the Chesapeake Caroline and Dorchester County Organization Types The Counties have a wide variety of government and large health-system affiliated organizations, and a smaller amount of large, national organizations. There are also several coalition-based groups like the Dorchester Wellness Coalition and the Partnership for a Drug-Free Dorchester, among others. There are also several government/county organizations, including county Social Service Departments.


Using the survey results, researchers were able to determine which organizations in the Counties had the highest number of in-degree and out-degree centrality. In other words, these organizations had the highest number of incoming and outbound connections to others in the network and most of them completed the survey. The range goes as follows: Nine out of the top 10 and 20 out of the top 25 most central organizations all completed the survey. They also provided important information about their relationships with other, less well-connected organizations, providing the research team with a stronger view into how the local network operates.

________________________________________________________________________________________________________



Overall, the online survey was used to gather information about healthcare organizations in Caroline/Dorchester Counties, find out who they partnered with, whether those organizations were in the Counties or elsewhere, and to collect quantitative and qualitative information about those relationships. The entire online survey can be viewed in Appendix B.

SECTION 1: HEALTHCARE ORGANIZATIONS: INFORMATION











Question 3 asked survey respondents to list their official job title. In Caroline/Dorchester Counties, the vast majority of responses were completed by decision makers with job titles that referenced managerial or executive capacity. The most common job title was Director or Executive Director (28%). When including executives/founders, managers, and directors, 64% of decision makers at high levels completed the survey for Caroline/Dorchester Counties. All survey respondents’ job titles are listed by percentage in Figure 5-5 on the following page.

________________________________________________________________________________________________________


Figure 5-5: Online Survey (Q3) – Survey Respondent Job Titles in Caroline/Dorchester Counties




The next question asked survey respondents to state whether their organization was a Diabetes Program Partner (DPP) or not. In Caroline/Dorchester Counties, no organization identified itself as a DPP.

Nursing8%

Business5%

Religious6%


Education11%


28%

Manager17%

Community-based6%


________________________________________________________________________________________________________



The last question in Section 1 asked respondents if their organization focused more on providing healthcare services or developing healthcare awareness. Organizations in the Counties tied: 50% of survey respondents said their organization’s focus was on delivering healthcare services and 50% said they focused on developing awareness of chronic health issues. The answers about organization focus are represented in Figure 5-6 below. Figure 5-6: Online Survey (Q6) – Organization Focus: Healthcare Awareness or Service Delivery


Section 2 presented survey respondents with a list of healthcare organizations in Caroline/Dorchester Counties and asked them to select the ones they partnered with.


Question 7 asked survey respondents to view a list of healthcare organizations in Caroline and Dorchester Counties and select the ones that they partnered with on various chronic health issues. This enabled the research team to compile of list of the most frequently selected healthcare organizations in the Counties, according to the survey respondents. Table 5-6 below lists the most-frequently selected healthcare organizations in the Counties, ranked by the percentage of survey respondents who listed them as a partner. For example, the





0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%


________________________________________________________________________________________________________


first entry on the list is Associated Black Charities, with 65% – this means that a full 65% of the organizations surveyed said that Associated Black Charities was one of their partners. Table 5-6: Top 20 Healthcare Organizations in Caroline/Dorchester Counties (by % selected in the survey)


1. Associated Black Charities 65%

2. Shore Health Systems 58%

3. Caroline County Health Department 58%

4. DHMH - Healthiest Maryland Businesses - Lower Eastern Shore 52%

5. Choptank Community Health Systems 52%

6. Dorchester County Health Department 48%


8. American Diabetes Association 45%

9. Dorchester County Health Department - HEZ Network 42%

10. Maryland Department of Health - Minority Outreach (MOTA) 39%

11. YMCA of the Chesapeake 39%

12. Judy Center 39%

13. Eastern Shore Area Health Center (ES AHEC) 39%

14. Centers for Disease Control 39%

15. Dorchester County Department of Social Services 35%

16. Dorchester County Wellness Coalition 35%

17. Dri-Dock Recovery and Wellness Center 35%

18. Caroline County Health Department - Women, Infants, and Children (WIC)

35%

19. University of Maryland Eastern Shore - School of Pharmacy 29%

20. University of Maryland Shore Regional Health 29%

The top 20 organizations listed above are very well-connected and tend to be government or major health system-affiliated, but there are several smaller organizations on the list that are well-connected despite their relatively smaller size. Associated Black Charities and Dri-Dock Recovery and Wellness Center are two examples.


Section 3 of the survey asked healthcare organizations about the type of relationships they had with the partner organizations they selected previously in Section 2. For every organization they selected, survey respondents were able to provide information about that partner with regard to upstream/downstream relationships, the length of their relationship, the frequency with which they communicated with partners, their understanding

________________________________________________________________________________________________________


of their partners’ skills and knowledge, and finally, their primary means of communication with partners.


After survey respondents selected the organizations they worked with, subsequent survey questions asked them to provide information about the nature of their relationship with those partners. The first question in Section 3 asked respondents to name which organizations gave them information (also known as an “upstream” relationship) and which organizations they sent information to (also known as a “downstream” relationship.) The list of the top organizations in terms of downstream partners is listed on the following page in Table 5-7. According to survey respondents, the organizations on this list are distributing information or providing referrals to others on a frequent basis. Table 5-7: Organizations with the Highest Number of Downstream Partners, Caroline and Dorchester Counties



2. Shore Health Systems 11

3. Caroline County Health Department 10

4. Centers for Disease Control 10


6. DHMH - Healthiest Maryland Businesses - Lower Eastern Shore 8

7. Choptank Community Health Systems 7

8. Eastern Shore Area Health Center (ES AHEC) 6

9. Associated Black Charities 6

10. Rose Hill Practitioners 5

11. University of Maryland - Extension 5

12. Three Lower Counties Community Health System 5

13. University of Maryland Eastern Shore - School of Pharmacy 5

14. Dorchester County Health Department - HEZ Network 4

15. Dorchester County Health Department 4


17. University of Maryland Shore Regional Health 4

18. Dri-Dock Recovery and Wellness Center 4

19. Dorchester County Department of Social Services 4

20. Dorchester County Wellness Coalition 3

________________________________________________________________________________________________________



Question 9 asked survey respondents about the length of the relationships with the organizations they named as partners. A scale with 5 options was presented, with “Less than 1 year” to define the briefest relationship, and “More than 10 years” to define the longest-lasting relationships. In Caroline/Dorchester Counties, survey respondents reported that the more established, larger health organizations were the ones they tended to have the longest relationships with. The organizations with the highest number of long-lasting relationships are listed in Table 5-8 below. Table 5-8: Organizations with the Highest Number of Partner Relationships Longer Than 10 Years





4. Centers for Disease Control 7

5. Caroline County Health Department - Social Services 6



8. Dorchester Early Head Start Program 5

9. Judy Center 5

10. Maryland Department of Health - Minority Outreach (MOTA) 5

11. Caroline County Health Department - Women, Infants, and Children (WIC)

5



14. Dorchester County Public Schools 4

15. Dorchester Co. School-based Wellness Programs 4


17. Dorchester County Recreation & Parks 3

18. Shore Pediatrics 3

19. University of Maryland Extension - 4-H Youth Development 3



Question 10 asked survey respondents how often they communicated with other organizations in their network. A scale with 4 options was presented, with “Frequently” to define the highest level of contact, followed by “Sometimes,” “Seldom,” or “Never” to describe less frequent levels of contact.

________________________________________________________________________________________________________


Overall, survey respondents reported that the more established, larger health departments, medical centers/hospitals and large community organizations were the ones they tended to communicate with the most. Those organizations, with the highest levels of “Frequent” communication, are listed in Table 5-9 below. Table 5-9: Top 20 Organizations with Highest Level of Frequent Contact with their Partners

Organization # Partners





5. Dorchester Co. Health Department Health Enterprise Zone 11







12. Dorchester Co. School-based Wellness Programs 7

13. University of Maryland Shore Regional Health 6

14. Three Lower Counties Community Services 6


16. Judy Center 6


18. Dorchester County Public Schools 6

19. Dorchester County YMCA 6



Question 11 asked survey respondents if they understood the skills and knowledge of each of the organizations they selected as partners. They were able to choose from a scale from highest to lowest, starting from “Strongly Agree, Agree, Disagree, or Strongly Disagree.” Overall, the largest group of respondents (63%) said they “strongly agree” that they understand the skills/knowledge of the organizations that they partner with. In total, 96% of survey respondents agreed or strongly agreed that they understood the skills and knowledge of the contacts at the organizations they partner with. The responses, listed by percentage, are shown in Figure 5-7 below.

________________________________________________________________________________________________________




Question 12 asked survey respondents what their primary means of communication was with their partners – whether via telephone, text message, e-mail, or in-person meetings. Each survey respondent was given an opportunity to answer the question specifically for each organization they deal with. Like the other networks, e-mail was the primary means of communication for most of the organizations, at 36%. In-person meetings were second, with 34%. Telephone contacts were 26% and text messages were three percent. Text messages, while small, was the highest reported number of all networks. The full results are listed in Figure 5-8 below.

63%

33%

4%0%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



________________________________________________________________________________________________________



IN-PERSON MEETINGS

Given that a good amount of contact between healthcare partners in Caroline/Dorchester Counties is done in-person (according to the organizations surveyed), the research team used the results to find out which organizations were reported to have frequent in-person meetings with their contacts. The organizations listed in Table 5-10 below had the highest number of survey respondents who said in-person meetings were their primary means of contact with that organization.

36% 34%

26%

3%

0%

10%

20%

30%

40%

50%

60%

70%

80%

90%

100%



________________________________________________________________________________________________________



Organization # of Respondents






6. Dorchester County Health Department - HEZ Network 7






12. Affiliated Sante Group 5


14. YMCA of the Chesapeake 5


16. Maryland Health Exchange - Dorchester County Navigator 4

17. Maryland Healthy Weighs 4

18. Dorchester County YMCA 4

19. Chesapeake Multicultural Resource Center 4

20. Partnership for a Drug Free Dorchester 4

________________________________________________________________________________________________________


REFERENCES

Smith, M., Milic-Frayling, N., Shneiderman, B., Mendes Rodrigues, E., Leskovec, J., Dunne, C.,

(2010).Node XL: a free and open network overview, discovery and exploration add-in for Excel 2007/2010, http://Node XL.codeplex.com from the Social Media Research Foundation, http://www.smrfoundation.org

Valente T., Chou C., and Pentz M. (2007). Community coalitions as a system: Effects of network

change on adoption of evidence-based substance abuse prevention. American Journal of Public Health, 97(5): 880-886.

________________________________________________________________________________________________________


APPENDIX A: QUERY LETTER FOR SNOWBALL SAMPLE

Dear ____:

The Maryland Department of Health and Mental Hygiene has partnered with the University of

Baltimore Schaefer Center for Public Policy to examine how local health organizations work

together to deliver health services related to diabetes and hypertension prevention, weight

management, blood pressure management, and heart health efforts.

The research team is conducting a social network analysis to map the network of the organizations involved in local health initiatives. Your organization has been identified by the Maryland Department of Health and Mental

Hygiene Department of Chronic Disease and Prevention as an organization working to address

these chronic health issues.

We are contacting you to invite you to be part of this analysis by completing the attached

spreadsheet to identify the organizations you work with to address these chronic health issues.

The spreadsheet already includes some of the organizations involved in your local health

network. Please extend this list by adding up to 20 additional organizations with whom you

work on hypertension and diabetes management.

In about three weeks, you and representatives of the organizations you identify will be

contacted to complete a short survey about the organizations you work with. Your participation

in the survey is completely voluntary. The names of the organizations identified in this survey

will be included in the social network report produced through this research.

If you have questions about this research, please contact:

Aaron Wachhaus, Ph.D. Principal Investigator Assistant Professor, University of Baltimore College of Public Affairs 1420 N. Charles Street Baltimore, MD 21201 410-837-6113 [email protected]

Kristi Pier, MHS, MCHES Director, Center for Chronic Disease Prevention and Control Maryland Department of Health and Mental Hygiene 201 W. Preston St Baltimore, MD 21201 410-767-6722 [email protected]

This research has been review and approved by the University of Baltimore and the Maryland Department of Health and Mental Hygiene’s Institutional Review Boards. If you have questions



________________________________________________________________________________________________________


about your rights as a participant in this research study, contact the following Institutional Review Board coordinators:

University of Baltimore IRB Coordinator Ms. Jocelyn Kucar, CRA IRB Administrator University of Baltimore 1420 N. Charles Street Baltimore, MD 21201 410-837-6199 [email protected]

Department of Health and Mental Hygiene IRB Coordinator Ms. Gay Hutchen IRB Administrator Institutional Review Board 201 W. Preston Street Baltimore MD 21201 410-767-8448 [email protected]

Thank you for your participation in this important research. Sincerely, Aaron Wachhaus, Ph.D. Principal Investigator Assistant Professor, University of Baltimore



________________________________________________________________________________________________________


APPENDIX B: ONLINE SURVEY

Introduction The Maryland Department of Health and Mental Hygiene (DHMH) has partnered with the University of Baltimore Schaefer Center for Public Policy to examine how local health organizations work together to deliver health services related to diabetes and hypertension prevention, weight management, blood pressure management, and heart health efforts. The research team is conducting a healthcare network analysis to map the network of organizations collaborating on these issues. Your organization has been identified by DHMH as an important organization working to address these chronic health issues. We are inviting you to be a part of this study by completing a short survey about the organizations you work with to address these chronic health issues. The survey data will be used to strengthen the network. Your participation in the survey is completely voluntary. The names of the organizations identified in this survey will be included in the report produced through this research.

If you wish to proceed with this survey, please click here.

If you do not wish to proceed with this survey, you may exit by clicking here.

Demographic Information

What is the name of your organization?

If applicable, the division or department you work at in this organization.

What is your title at this organization?

Which sector best describes this organization?

Business

Health System

National DPP

Government

Community

Education/Academia

Philanthropy

Is your organization a Diabetes Program Partner (DPP)?

________________________________________________________________________________________________________


Yes

No

Does your organization focus more on:

developing awareness of hypertension, diabetes, or heart health

delivering services to prevent or mediate hypertension, diabetes, or heart health

Of the organizations that you previously selected in the last question, please indicate which are: "downstream" from you - organizations that you send information or resources to - or "upstream" from you - organizations that you get referrals, information or resources from.

Downstream (1)

Upstream (2)

The next series of questions are about each organization that you selected earlier. How long have you had a working relationship with each organization?

Less than 1 year (1)

1-3 (2)

3-6 (3)

6-10 (4)

More than 10 (5)

What is the frequency with which you typically communicate with each organization?

Never (1)

Seldom (2)

Sometimes (3)

Frequently (4)

I understand the skills and knowledge of my main contacts at this organization:

Strongly Agree (1)

Agree (2)

Disagree (3)

Strongly Disagree (4)

What is your primary means of communication with your main contact at each organization?

Telephone (1)

Text Message (SMS) (2)

Email (3)

________________________________________________________________________________________________________


In-person Meetings (4)

The survey has ended. Your time and effort is appreciated, and will help us better understand this collaborative network. Thank you for participating.

________________________________________________________________________________________________________


APPENDIX C: BALTIMORE CITY ORGANIZATIONS – DEGREE AND CENTRALITY SCORES

Organization In-

Degree Out-

Degree Betweenness

Centrality

Access to Wholistic & Productive Living Institute, Inc. (AWPLI) 3 0 0.118

Advocates for Children and Youth (ACY) 9 0 22.573

Advocates for Survivors of Torture and Trauma (ASTT) 3 0 2.152

Allegany County Health Dept. 5 5 24.620

Alliance for a Healthier Generation 5 0 3.003

American Academy of Pediatrics 12 12 641.338

American Cancer Society 21 3 562.559

American Diabetes Association 37 79 7026.511

American Diabetes Association - Community Outreach 0 53 1969.881

American Heart Association 46 69 5438.999

American Heart Association - Cooking with Heart Kitchen 24 0 121.837

American Legacy Foundation 7 0 3.735

American Lung Association 16 0 112.363

Amerigroup MCO 13 0 89.115

Anne Arundel County Health Department 5 0 2.572

Ashland Commons Multi-dwelling Apartments 1 0 0.000

Asylum Women's Enterprise (AWE) 1 0 0.000

Baltimore American Indian Center 1 0 0.000

Baltimore City - Dept. of Health - Office of Chronic Disease Prevention

28 38 1461.371

Baltimore City - Dept. of Parks and Recreation 17 10 254.618

Baltimore City - Mayor's Office of Neighborhoods 17 0 170.744

Baltimore City - Office of Aging & Care Services 23 16 412.888

Baltimore City - Office of Sustainability 9 31 441.288

Baltimore City - Wellness Program 11 0 7.402

Baltimore City Community College 5 0 2.130

Baltimore City Dept. of Health - Tobacco Use, CVD Prevention 16 0 64.092

Baltimore City Fire Department 9 5 12.746

Baltimore City Health Department 41 39 2502.670

Baltimore City Health Department - B'more for Healthy Babies 23 53 3119.361

Baltimore City Health Department - Community Relations 0 94 7995.081

Baltimore City Health Department - Immunization 0 0 0.000

Baltimore City Health Department - Maternal and Child Health 21 0 123.711

Baltimore City Health Department - Youth Health 0 13 60.545

Baltimore City Health Dept. - Baltimarket 17 43 1813.279

Baltimore Community Foundation 10 0 55.797

Baltimore County Department of Aging 14 20 1098.414

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Baltimore County Health Dept. - Clinical Services 6 0 15.168

Baltimore County Public Schools 9 0 60.296

Baltimore Curriculum Project 4 0 2.794

Baltimore Medical System, Inc. 13 0 26.110

Baltimore Stops 4 0 0.047

Baltimore-Washington United Methodist Church 2 0 1.815

Behavioral Health System Baltimore, Inc. 12 0 46.595

Bel-Park Towers 1 0 0.000

Bernard E. Mason Assisted Living/Food Pantry 0 0 0.000

Bethel AME Church 7 0 5.139

Bi-Rite Grocery Store 1 0 0.000

Black Mental Health Alliance 9 0 27.765

Black Nurses Association of Baltimore, Inc. (BNAB) 5 7 102.448

Bmore Fit 18 0 46.416

Bon Secours - West Baltimore Health Enterprise Zone 24 53 2082.892

Bozzuto Homes 1 0 0.000

Breast and Cervical Cancer Diagnosis and Treatment Program 6 0 5.693

Calvert County Public Schools 4 0 5.946

Carefirst Blue Cross Blue Shield 12 0 99.170

Caroline Center 1 0 0.000

Caroline County Public Schools 5 2 25.414

Carroll County Public Schools 3 5 7.491

Catholic Charities Headstart 6 9 99.313

Catholic Charities of Maryland 9 0 19.773

CEASE (Smoke-free Baltimore) 11 20 232.616

Cecil County Public Schools 4 1 8.551

Celebration Church 2 0 0.000

Center for Grace-Full Living - Amazing Grace Evangelical Church 0 22 1724.716

Center for Urban Families 7 0 12.681

Central Baptist Church 5 45 857.181

CHAI - Northwest Neighbors Connecting 1 7 8.501

Charles County Health Department 7 0 8.189

Chase Brexton 16 0 197.039

Civic Works Real Food Farm 5 10 184.932

Clay Pots Baltimore 1 0 0.000

Coppin State University 21 0 153.253

Cor-les Consultants 1 0 0.000

Dance and Be More 2 0 0.413

DDC Total Health 4 0 0.257

Delmarva Foundation 15 33 716.620

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

DHMH Comprehensive Cancer Control Program 0 5 1.530

DHMH Environmental Health Bureau (Asthma Control Program) 8 19 418.852

DHMH Surveillance and Policy Analysis 2 0 0.395

Diabetic Retinopathy Program – Johns Hopkins 0 0 0.000

Dorchester County Public Schools 4 0 5.946

Druid Heights Community Development Corp. 8 0 14.059

East Baltimore Medical Center 10 0 66.622

Edmondson Heights 7th Day Adventist Church 0 0 0.000

Equity Matters 4 0 1.598

Evangelical Lutheran Church in America 1 0 0.000

Faith Baptist Church 5 0 8.874

Faith Lutheran Evangelical Church 1 0 0.000

Family League of Baltimore 16 0 64.189

Family Planning Comprehensive Clinic/Healthy Teens & Young Adults

0 0 0.000

Fleming Senior Center 2 0 0.000

Food Depot 7 0 15.114

Forest Park Reformed Church 0 0 0.000

Frederick County Health Department 4 0 2.478

Fulton Baptist Church 3 0 1.155

FutureCare Sandtown/Winchester 6 11 74.299

Garrett County Public Schools 5 0 7.091

General Growth Properties - Mondawmin Mall 2 0 0.000

Gilmore Homes 6 0 19.352

Good Will - Chesapeake 4 0 6.901

Green & Healthy Homes Initiative 7 0 40.734

Harford County Public Schools 5 0 13.737

Healing Connections 0 0 0.000

Health Freedom, Inc. 8 0 5.672

HealthCare Access Maryland 18 2 133.168

Healthy Heartbeats 5 0 1.137

Helping Up Mission 8 0 41.728

Higher Dimension Christian Center 2 0 1.155

Holistic Life Foundation 2 0 0.000

HOPE Project 3 0 2.740

Housing Authority of Baltimore City (HABC) 16 0 117.601

Howard County Public Schools 8 11 208.720

Impacting Tomorrow Health Center 0 0 0.000

Institute for Integrative Health 7 0 12.522

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Institute for Public Health Innovation 5 2 13.688

Institute of Human Virology - Project Shalem (Faith Based) 0 0 0.000

Ivy Family Services 2 0 1.604

James Long Fitness 7 61 3151.394

Johns Hopkins - Bloomberg School of Public Health 34 50 4004.001

Johns Hopkins - Broadway Center for Addiction 5 10 138.744

Johns Hopkins - Center for a Livable Future 12 0 12.946

Johns Hopkins - Center for Adolescent Health 7 37 1390.596

Johns Hopkins - Center To Eliminate Cardiovascular Health Disparities

5 23 816.145

Johns Hopkins - Community and Global Programs 0 52 4210.666

Johns Hopkins - Environmental Justice Partnership 1 0 0.000

Johns Hopkins - Henderson-Hopkins Health and Wellness Fair 3 0 6.902

Johns Hopkins - Kimmel Cancer Center 5 0 3.200

Johns Hopkins - Priority Partners MCO 7 0 10.951

Johns Hopkins - School of Nursing 14 0 126.791

Johns Hopkins - The Access Partnership (TAP) 3 0 0.000

Johns Hopkins - The Welch Center 2 0 0.000

Johns Hopkins - Women, Infants, and Children Program (WIC) 7 0 23.387

Johns Hopkins AIDS Education and Training Center 0 12 78.309

Johns Hopkins Hospital 13 0 164.776

Johns Hopkins Nutrition 4 0 17.165

Johns Hopkins Office of Community Health/Belair-Edison Healthy Community Coalition, Inc.

6 18 277.364

Johns Hopkins School of Nursing - East Baltimore Community Nurse Center (EBCNC)

12 21 926.145

Johnston Square Apartments 5 0 15.082

Kent County Health Department - School Health 6 4 10.808

Keystone Pharmacy 0 0 0.000

Latino Providers Network 7 0 10.309

Les Gemmes Social Club 0 0 0.000

Lexington Market 11 0 33.502

Liberty Senior Center 4 0 0.000

Life Restoration Ministry 1 0 0.000

Lifebridge Health 12 0 28.862

Light Health 4 0 11.496

Lillian Jones Apartments 2 0 1.202

Living Classrooms 8 0 12.848

Macedonia Baptist Church 2 5 7.748

Manna Bible Baptist Church 3 0 1.155

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Maryland Academy of Nutrition and Dietetics 5 0 9.412

Maryland Assoc. of Student Councils 4 0 3.250

Maryland Dental Action Coalition 5 10 15.173

Maryland Dept. of Education - Curriculum, Assessment, and Accountability

5 13 91.393

Maryland Dept. of Education - Early Childhood Development 9 3 32.123

Maryland Dept. of Education - Nutrition Environment & Services 9 0 15.213

Maryland Dept. of Education - School Health Services 12 41 1399.679

Maryland Dept. of Education - Student, Family, and School Support 4 30 1059.208

Maryland Dept. of Health - Behavioral Health Admin. 9 0 37.417

Maryland Dept. of Health - Cancer and Chronic Disease Bureau 12 0 91.213

Maryland Dept. of Health - Chronic Disease Prevention and Control 24 0 273.945

Maryland Dept. of Health - Ctr. for Tobacco Prevention & Control 15 0 138.280

Maryland Dept. of Health - Maternal and Child Health 9 0 16.440

Maryland Dept. of Health - Nutrition Environment & Services 6 0 7.955

Maryland Dept. of Health - Office of Population Health Improvement 5 0 3.196

Maryland Dept. of Health - Office of Population Health Improvement - State Health Improvement Process (SHIP)

4 0 4.872

Maryland Dept. of Health - Office of School Health 11 0 41.561

Maryland Dept. of Health - Women, Infants, & Children (WIC) 13 0 86.053

Maryland Dept. of Health (DHMH) 37 0 1272.023

Maryland Dept. of Public Safety and Correctional Services 9 0 50.990

Maryland Environmental Health Network 4 0 1.535

Maryland Family Network 7 0 30.011

Maryland Hunger Solutions 9 92 7056.278

Maryland Out of School Time (MOST) Network 8 18 242.696

Maryland Physicians Care MCO 5 0 10.964

Maryland State - Department of Human Resources 11 0 125.340

Maryland State Department of Education, Community Nutrition Branch

7 0 11.808

MDQuit Tobacco Resource Center 16 51 3115.362

MedChi 6 0 6.990

MedStar Franklin Square Medical Center 0 26 476.593

MedStar Good Samaritan Hospital 0 7 16.271

MedStar Good Samaritan Hospital - Community Outreach 0 10 57.338

MedStar Harbor Hospital 0 2 0.263

MedStar Health and Hospital System 22 0 447.005

Men and Families Center 6 0 28.478

Meritus Health System - School Health Services 1 6 14.722

Mobile Optical, Inc. 2 9 40.719

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Montgomery County Health Department 5 0 3.420

Monumental City Medical Society 3 13 42.062

Morgan State University 22 19 858.824

Mosaic Community Services 4 17 260.680

Moveable Feast 15 19 870.777

Moveable Feast - Nutrition Services 0 22 312.304

Mt. Lebanon Baptist Church 5 0 2.238

National Alliance on Mental Illness 3 0 2.764

National Institutes of Health (NIH) 11 0 21.664

National Kidney Foundation of Maryland 4 0 4.233

New Christian Memorial Church 2 0 0.000

New Psalmist Baptist Church 8 0 4.042

New Shiloh Baptist Church - Nurses' Ministry 10 44 1269.834

New Song Community Church 6 0 15.934

New Vision House of Hope 6 0 0.143

Newborn Community of Faith 3 0 1.114

No Boundaries Coalition 6 5 65.621

North West Round Table 0 0 0.000

O Herbals 0 0 0.000

Omega Psi Phi Fraternity 7 0 3.962

OWEL (Older Women Embracing Life) 3 0 6.483

Park Heights Community Health Alliance 10 0 12.540

Parkview Apartment for Seniors 5 0 20.745

PATH (People Acting Together in Howard) 2 0 0.000

Paul's Place 12 0 55.904

Payne Memorial AME Church 5 0 2.082

Pharmacy Solutions 1 0 0.000

Pleasant View Gardens Senior Building 8 0 28.549

Pratt Library - Orleans Street 4 0 2.632

Pratt Library - Southeast Anchor 1 0 0.000

Prince George's County Public Schools 5 0 7.061

Priority Partners MCO 10 0 52.986

Promise Heights 6 0 2.962

Queen Anne's County Health Department 8 8 76.794

Radical Life Coach 0 0 0.000

Real Food for Kids - Montgomery County 4 7 50.548

Riverside Health MCO 10 0 46.587

Saint Agnes Hospital 18 14 663.051

Sandtown Foot and Ankle 0 0 0.000

Share Our Strength 9 0 7.083

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Shepherd's Clinic for the Uninsured 5 2 65.062

Sheppard Pratt Health System 7 0 32.741

Shiloh A.M.E. Church 3 0 0.000

Shoppers Food (Mondawmin Mall) 5 0 0.000

Sinai Hospital 15 0 94.614

Sisters Together And Reaching (STAR) 17 0 206.078

Somebody Cares Baltimore 1 0 0.000

Somerset County Public Schools 5 4 16.577

St. Mark's Institutional Baptist Church 2 0 0.000

St. Agnes Hospital - Maryland Metabolic Institute 6 0 3.310

St. Bernardine's Parish 1 0 0.000

St. Joseph Free Will Baptist Church 1 0 0.000

St. Mary's County Public Schools 4 12 259.901

Stratford University 1 0 0.000

Sugar Free Kids Maryland 14 40 1595.551

Talbot County Health Department 7 0 18.685

The Danya Institute, Inc. 3 11 64.456

The Horizon Foundation 12 43 1896.394

The Parents' Place of Maryland 1 0 0.000

The Tabernacle of the Lord 4 0 0.000

The Women's Housing Coalition 2 0 0.000

Timothy Baptist Church 2 0 0.000

Total Health Care, Inc. 0 6 7.006

Total Health Care, Inc. - Community Programs 24 57 2686.378

Total Health Now 2 0 0.000

Towson University - Dept. of Kinesiology 3 0 12.310

Transformation Church 3 0 1.155

Trinity Baptist Church 5 0 8.798

UC San Francisco - Smoking Cessation Leadership Center 2 0 0.000

Union Baptist Church 7 0 5.880

United Health Care MCO 6 0 31.210

University of Maryland 16 0 132.506

University of Maryland - Center for Diabetes and Endocrinology 5 0 8.414

University of Maryland - Center for School Mental Health (CSMH) 5 0 13.388

University of Maryland - Center for Substance Abuse Research 1 0 0.000

University of Maryland - Institute for a Healthiest Maryland 10 0 23.646

University of Maryland - Legal Resource Center for Public Health Policy

10 29 620.377

University of Maryland - Nutrition and Food Science 9 0 7.819

University of Maryland - School of Medicine 13 10 328.971

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

University of Maryland - School of Pharmacy 9 0 25.774

University of Maryland - School of Public Health 15 0 143.895

University of Maryland - School of Social Work 11 0 117.988

University of Maryland College Park 6 0 5.100

University of Maryland Extension 12 59 3125.039

University of Maryland Medical Center 15 44 2207.931

University of Maryland Medical Center - STAR TRACK Program 4 0 9.715

Urban Farmers 6 0 2.401

Urban League 6 0 26.712

Waters A.M.E. 3 0 10.079

Waters Towers 1 0 0.000

Waxter Center for Senior Citizens 14 0 47.879

Wayland Baptist Church 5 0 1.395

Wicomico County Board of Education 4 0 4.245

Women Accepting Responsibility 5 0 1.622

Woodlawn Senior Center 5 0 4.717

Y of Central Maryland 0 50 1633.496

Y of Central Maryland - Community Relations 26 44 1968.919

Zeta Center Healthy Aging Partnership (Z-HAP) 21 61 3350.614

________________________________________________________________________________________________________


APPENDIX D: WASHINGTON COUNTY ORGANIZATIONS – DEGREE AND CENTRALITY

SCORES

Organization In-

Degree Out-

Degree Betweenness

Centrality

Allegany College Nurse-Managed Wellness Center (NMWC) 4 3 0.000

Allegany County HRDC 3 8 7.000

Asbury United Methodist Church 3 0 9.586

Big Brothers Big Sisters 3 0 0.000

Blossom School of Etiquette 0 0 0.000

Brooklane Hospital 6 0 5.651

Brothers Who Care 3 28 1610.316

Caldwell Manufacturing 4 2 2.354

Calvary Temple Apostolic Church 0 0 0.000

Capital Women's Care 5 9 30.505

Cardiovascular Center of Hagerstown 4 0 1.579

Chase Brexton 0 0 0.000

Children In Need 1 0 0.000

City of Hagerstown 7 0 23.082

College View Nursing Home 1 0 0.000

Community Foundation of Washington County 2 0 0.000

Community Free Clinic 9 0 7.681

Cumberland YMCA 5 6 41.432

Datta Endocrine & Wellness Center 3 0 0.000

DaVita Dialysis Center 1 9 375.867

Doleman Black Heritage 0 0 0.000

Ellsworth Electric 0 0 0.000

Fahrney Keedy Home and Village 4 0 61.594

Fit in BoonsBoro 2 4 0.500

Francis Murphy Senior Nutrition Site 0 0 0.000

Frederick Memorial Hospital 3 0 4.095

Frostburg State University - Brady Health Center 2 2 2.808

Garrett College 2 0 0.000

Girls, Inc. of Washington County 3 9 111.321

Greater Campher Temple 1 0 0.000

Hagerstown Heart 6 0 2.765

Hagerstown Volvo Group/Staywell Program 4 0 2.106

Hagerstown YMCA 4 0 2.941

Hancock Senior Nutrition Site 1 0 0.000

HBP, Inc. 1 1 0.000

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Head Start of Washington County 4 0 12.668

HEAL of Washington County 11 29 1384.887

Hispanic Association of Hagerstown 2 0 1.449

Hospice of Washington County 6 0 17.531

Hub Labels 2 0 5.586

International Corporate Training and Marketing 0 0 0.000

Johns Hopkins - Community Physicians 4 0 4.419

Johns Hopkins University - Comstock Center 2 15 221.033

Kaplan University 1 0 0.000

Kassandra's Cultural Center 1 1 4.831

Keller Stonebraker 2 4 18.657

Maryland Department of Aging 8 0 24.267

Maryland Department of Health 14 0 154.300

Maryland Department Of Social Services 6 0 17.531

Maryland Diversity Center 1 0 0.000

Maugansville Garden Apartments 1 0 0.000

Meadow Kidney Care 2 7 63.684

Meritus Health 16 0 122.234

Meritus Health - Parish Nursing 7 26 505.011

Meritus Home Health Care 10 0 27.076

Meritus Medical Center 16 22 1075.934

Meritus Medical Center, Behavioral & Community Health 0 19 192.706

Meritus Medical Center, Community Health Education & Wellness

0 18 138.147

Meritus Total Rehab Care - Wellness Center 4 0 1.834

Meritus Weight Loss Center 5 0 0.250

Merkle 1 0 0.000

NAACP - Washington County 1 0 0.000

Northampton Manor Rehab Center 1 0 0.000

Planet Fitness 1 0 0.000

Potomac Towers 3 0 0.461


Progressive Men's Club 1 0 0.000

Robert W. Johnson Community Center 4 0 9.205

Robinwood Family Practice 8 0 10.963

Robinwood Heart 4 0 0.536

Ruff Fitness 4 0 7.760

San Mar Children's Home 4 0 14.956

Second Christian Church 1 0 0.000

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Smithsburg Senior Nutrition Site 1 0 0.000

Soul Food Ministries 1 0 0.000

Southeastern Senior Nutrition Site 0 0 0.000

Staples Distribution 0 0 0.000

Steve Swayne Insurance 1 0 0.000

The Arc of Washington County 3 29 805.329

The Kidney Center of Hagerstown 3 0 19.717

Town of Williamsport 2 0 0.000

Tri-State Community Health Center 7 1 11.046

United Health Care 0 0 0.000

United Way 6 0 25.499

University of MD Extension Office 5 20 282.761

VA Medical Center, Martinsburg, WV 3 0 8.583

Walnut Street Community Health Center 10 19 464.454

Walnut Towers 4 0 1.022

Washington County - Board of Education 5 0 1.449

Washington County - Commission on Aging 10 28 1035.100

Washington County Department of Social Services 0 9 42.263

Washington County Health Department 17 25 916.616

Washington County Public Schools 11 0 102.089

Way Station Behavioral Health 2 13 147.256

Western Maryland Health Systems 14 0 166.939

Western MD AHEC 4 15 271.794

Western MD Hospital 9 0 48.393

Williamsport Senior Nutrition Site 1 0 0.000

Zion Baptist Church 2 0 1.449

________________________________________________________________________________________________________


APPENDIX E: WESTERN MARYLAND ORGANIZATIONS – DEGREE AND CENTRALITY SCORES

Organization In-

Degree Out-

Degree Betweenness

Centrality

Advanced Diabetic Solutions 4 0 0.458

Allegany County Chamber of Commerce 1 0 0.000

Allegany County Department of Social Services 1 0 0.000

Allegany County Health Department 7 0 1.294

Allegany County Health Dept. - Adult Eval. & Review Svcs. 3 0 0.550

Allegany County Health Dept. - Cancer Prevention 4 30 186.505

Allegany County Health Dept. WIC (Women, Infants and Children) 1 14 36.354

Allegany County Human Resources Development Commission, Inc. 3 0 0.000

Allegany County Public Schools 10 0 5.947

Allegany Health Education Center 6 0 0.722

Allegany Health Right 1 0 0.000

Allegany Radio Corporation 1 0 0.000

Alzheimer's Association 3 6 2.028

Archway Station 12 3 58.291

Associated Charities of Cumberland 1 0 0.000

Braddock Medical Group 3 0 0.000

Carver Community Center 2 0 0.000

Chapman and Associates Healthcare 7 0 7.284

Children's Medical Group 1 0 0.000

County United Way 6 0 1.517

Crellin Elementary School 7 0 1.197

Dennett Road Nursing Home 15 25 282.746

Evergreen Heritage Center 6 6 18.243

Family Junction 6 0 0.612

Fechheimer Shirt Factory 7 5 4.859

Friendsville Elementary School 7 4 7.257

Frostburg Village Nursing and Rehab 5 0 0.793

Garrett College Community Aquatic & Recreation Complex / Great Garrett Adventure Camp

12 19 738.967

Garrett County - Area Agency on Aging 6 2 0.355

Garrett County Board of Education 0 0 0.000

Garrett County Health Department 4 26 182.591

Garrett County Memorial Hospital 4 0 0.167

Grantsville Elementary School 4 0 0.000

Hope Station 7 8 12.005

Housing Authority of the City of Cumberland 4 4 0.454

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Life Fitness Management 5 0 0.230

Maryland Physicians Care 8 4 11.889

Mid-Atlantic Healthcare 4 5 1.709

Mountain Health Alliance 11 0 13.274

Mountain Laurel Medical Center 7 22 211.854

Northern High School 4 0 0.000

Western MD Health System - Parish Nursing Program 6 13 84.539

PharmaCare 9 0 4.606

PharmaCare, Community Health & Wellness 9 24 199.295


Southern High School 7 0 6.021

Tri-State Community Health Center 10 29 250.353

University of Maryland Extension 12 24 346.746

Uno Pizzeria & Grill 15 32 407.424

Western Maryland Area Health Education Center 8 0 3.380

Western Maryland Health System 6 22 89.877

Western Maryland Medical Center 10 0 4.781

Western Maryland Regional Health Center, out-patient dialysis 8 0 4.090

Western MD Health System - Center for Clinical Resources 5 0 0.529

Western MD Health System - Diabetes Clinic 7 0 0.355

Western MD Health System - Pulmonary Rehab 5 0 0.000

YMCA 4 2 1.122

Yough Glades Elementary School 7 0 0.743

________________________________________________________________________________________________________


APPENDIX F: LOWER SHORE ORGANIZATIONS – DEGREE AND CENTRALITY SCORES

Organization In-

Degree Out-

Degree Betweenness

Centrality


Atlantic General Hospital 8 0 43.337

Carefirst BlueCross BlueShield 8 0 66.293

Casino at Ocean Downs 1 0 0.000

Chesapeake Multicultural Center 3 4 3.204

Chesapeake Pediatrics 1 0 0.000

Children’s Medical Group 1 0 0.000

City of Salisbury Government 2 0 1.425

Clear Channel Outdoor 3 0 6.955

Crisfield Clinic 5 0 4.339

Deer's Head Hospital Center 2 2 0.000

Hartley Hall Nursing Home 1 2 1.867

Herschel S. Horowitz Center for Health Literacy, University of Maryland

3 5 37.129

HOPE 1 10 48.352

Kent County Health Department 3 0 2.167

Lower Shore Family YMCA 9 9 116.522

Maintaining Active Citizens (MAC) 8 33 1132.430

McCready Foundation 8 0 15.749

Mt. Zion United Methodist Church 2 0 0.000

Ocean Pines Association 1 0 0.000

Peninsula Home Care 2 5 3.666

Peninsula Regional Medical Center 12 0 101.553

Pocomoke Elementary School 4 0 6.031

Pocomoke High School 3 0 0.000

Pocomoke Middle School 4 0 6.031

Pocomoke River State Park 2 0 0.000

Pocomoke Senior Center 1 0 0.000

Pocomoke Volunteer Fire Dept. 2 0 0.000

Public Access Channel PAC-14 3 3 5.981

Queen Anne's County Dept. of Aging (M4A) 1 0 0.000

ReConnections 1 8 37.714

Richard A. Henson YMCA 5 13 310.380

Salisbury Area Chamber of Commerce 2 0 0.000

Salisbury University 8 0 35.864

Shore Health Regional Medical Center 2 0 1.104

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Snow Hill Volunteer Fire Department 2 0 0.000

Somerset County Dept. of Parks & Recreation 2 0 0.000

Somerset County Health Department 7 7 49.460

Somerset County Health Department, Behavioral Health 0 12 59.074

Somerset Wellness Center 5 9 163.223

St. Paul's United Methodist Church 4 0 2.349

Taylor Bank 1 0 0.000

The Daily Times 4 0 6.010

Three Lower Counties (FQHC) 9 0 25.957

Three Lower Counties Community Services 8 7 70.716

Town of Berlin 3 5 4.341

Town of Ocean City - Parks and Recreation 2 0 0.000

Town of Snow Hill 2 0 0.000

VQHC 0 2 0.000

WBOC-TV 16 7 0 28.949

Wicomico County Board Of Education 4 0 10.409

Wicomico County Dept. of Recreation, Parks, and Tourism 2 0 0.000

Wicomico County Government 5 0 9.023

Wicomico County Health Department 12 30 716.179

Wicomico County Public Schools 2 7 35.835

Wicomico Public Libraries 1 2 0.400

Wicomico YMCA 3 0 4.098

WMDT-TV 47 7 0 52.189

Worcester County Board of Education 2 25 445.454

Worcester County Commission on Aging 3 0 6.856

Worcester County Department of Recreation and Parks 2 0 0.000

Worcester County Developmental Center 2 0 0.000

Worcester County Government 3 4 15.384

Worcester County Health Department 14 32 1711.331

Worcester County Local Management Board 4 0 1.458

Worcester County Parks and Recreation 4 0 1.733

Worcester County Public Schools 0 10 31.736

YMCA of the Chesapeake 0 11 47.960

________________________________________________________________________________________________________


APPENDIX G: CAROLINE AND DORCHESTER COUNTY ORGANIZATIONS – DEGREE AND

CENTRALITY SCORES

Organization In-

Degree Out-

Degree Betweenness

Centrality

4-H Cooperative Extension 6 0 0.881

Access to Wholistic & Productive Living Institute, Inc. (AWPLI) 1 10 11.322

Affiliated Sante Group 7 0 0.166

American Diabetes Association 14 0 8.389


Associated Black Charities 20 45 493.092

Atlantic General Hospital System 4 0 0.000

Caroline Co. Board of Education 4 0 0.000

Caroline Co. Parks and Recreation 3 0 0.000

Caroline County Department of Social Services 8 2 2.472

Caroline County Family YMCA 0 3 0.133

Caroline County Health Department 18 17 311.947

Caroline County Health Department - Wellness Programs 0 15 38.613

Caroline County Health Dept. - Women, Infants, and Children (WIC)

11 0 7.498

Centers for Disease Control 12 0 47.292

Channel Marker Mental Health Support 6 0 0.000

Chesapeake Hyatt 5 0 0.293

Chesapeake Multicultural Resource Center 9 10 14.539

Chesapeake Voyagers, Inc. 5 0 0.166

Chesapeake Women's Health 6 0 0.311

Chester River Health 5 0 0.611

Choptank Community Health Systems 16 34 311.345

Choptank Transport 4 2 1.866

Community Foundation of the Eastern Shore 6 0 0.000

Crossroads Community Incorporation 7 0 0.505

DHMH - Healthiest Maryland Businesses - Lower Eastern Shore 16 9 102.615

Dorchester Childcare Association 4 0 0.159

Dorchester Co. Health Dept. Health Enterprise Zone 16 0 62.308

Dorchester County Department of Social Services 11 0 7.134

Dorchester County Health Department 15 50 828.210

Dorchester County Health Department - Community Outreach 0 34 233.808

Dorchester County Health Department - Health Education 0 58 966.513

Dorchester County Health Department - School-based Wellness 9 4 10.138

Dorchester County Public Schools 6 0 1.260

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

Dorchester County Recreation & Parks 4 0 0.000

Dorchester County Wellness Coalition 11 0 1.976

Dorchester County YMCA 9 19 60.390

Dorchester County YMCA - Chronic Disease Prevention 0 3 0.604

Dorchester Early Head Start Program 7 4 2.286

Dorchester Ministerial Association 7 0 2.131

Down To Earth Deliverance Ministries 3 0 0.000

Dri-Dock Recovery and Wellness Center 11 0 2.036

Eastern Shore Area Health Education Center 12 37 303.653

Good Shepherd's Ministerial Association 4 0 0.159

Harvesting Hope 5 1 0.159

Internal Medicine - Dr. Mary-Anne Moore 6 0 0.320

Judy Center 12 0 11.045

Komen Foundation Breast Cancer Consortium 5 0 1.380

Maryland ACO of Western Maryland 0 0 0.000

Maintaining Active Citizens (MAC) 8 16 69.827

Maryland Health Connection - Dorchester Navigator 7 59 979.414

Maryland Healthy Weighs 7 12 16.746

Maryland Rural Health Association 6 0 0.186

Meant to Be 3 0 0.065

MedChi 4 0 0.061

N. Dorchester African & All Americans Indep. Growth Alliance 6 0 0.727

Old Trinity Church 4 6 6.953

Partnership for a Drug-Free Dorchester 7 0 0.061

Peninsula Home Care 4 0 0.000

Peninsula Regional Medical Center 8 11 54.334

Rose Hill Practitioners 5 0 0.166

Screenvision Cinema Advertising 2 0 0.000

Shore Health Systems 18 0 65.115

Shore Pediatrics 5 0 0.500

South Dorchester Good Neighbor 3 0 0.000

St. Luke's Church 7 0 6.269

Sugar Free Kids Maryland 4 0 0.000

Three Lower Counties Community Health System 8 0 2.084

Union Bethel AME Church 12 15 126.351

Univ. of Md - Shore Health Breast Cancer Center 4 0 0.000

University of Maryland - Extension 8 0 3.057

University of Maryland - Shore Regional Health 0 43 420.130

University of Maryland - Shore Regional Health (Easton) 9 8 30.792

________________________________________________________________________________________________________


Organization In-

Degree Out-

Degree Betweenness

Centrality

University of Maryland Eastern Shore - School of Pharmacy 9 10 39.420

University of Maryland Eastern Shore - School of Pharmacy - Evaluation

4 21 53.267

Visions America Healthcare 4 0 0.000

Waugh Chapel United Methodist Church 6 5 0.493

Wicomico County Health Department 8 0 1.131

WMDT - Channel 47 6 0 0.299

YMCA of the Chesapeake 12 7 57.911

Zeta Phi Beta Sorority - Stork's Nest Program 7 0 0.493

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